# Door-to-Balloon Time Delay in Complex Primary Angioplasty: A Case of Anomalous Origin of the Right Coronary Artery From the Pulmonary Artery (ARCAPA)

## TL;DR

A rare coronary anomaly complicated heart treatment, causing delays and requiring special care during emergency procedures.

## Contribution

This case highlights how coronary anomalies can complicate PCI and increase door-to-balloon time in STEMI patients.

## Key findings

- ARCAPA increased door-to-balloon time by about 20% compared to institutional median.
- Coronary anomalies can complicate PCI and require heightened awareness among interventional cardiologists.
- The case was confirmed using coronary computed tomography angiography.

## Abstract

Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a rare condition, with clinical presentations ranging from sudden cardiac death to heart failure, although most cases remain asymptomatic until adulthood. We report the case of a 58-year-old man who presented to the emergency department with chest pain and persistent ST-segment elevation in the lateral leads (DI and aVL) on electrocardiogram (EKG). Coronary angiography revealed a subocclusive stenosis of the ramus intermedius (RIA) of the left coronary artery. Failure to selectively engage the RCA during the procedure, together with visualization of collateral circulation on aortography, raised suspicion of ARCAPA. Primary angioplasty was performed on the RIA with the implantation of a biodegradable polymer biolimus-eluting stent. The presence of ARCAPA resulted in approximately a 20% increase in door-to-balloon time compared with the institutional median of 65 min. The anomaly was subsequently confirmed by coronary computed tomography angiography (CCTA). This case highlights that coronary anomalies can increase the complexity of percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction, prolong door-to-balloon times, and require interventional cardiologists to maintain a high level of awareness, understanding, and preparedness for such conditions.