Once in a Blue Moon: Iatrogenic Coronary Dissection in Anomalous Coronary Artery

Novel Teaching Points•The Lipton R-IP classification is the rarest SCA configuration, with the left coronary system originating from the right coronary periphery.•Percutaneous coronary intervention of the left coronary system may be very challenging in cases of Lipton’s R-IP classification.•Surgical revascularization is a reasonable strategy, especially when the coronary periphery is in the typical location.•An in-depth heart team approach is crucial to ensure the performance of “in-time” lifesaving treatments in such critical and complex cases. •The Lipton R-IP classification is the rarest SCA configuration, with the left coronary system originating from the right coronary periphery.•Percutaneous coronary intervention of the left coronary system may be very challenging in cases of Lipton’s R-IP classification.•Surgical revascularization is a reasonable strategy, especially when the coronary periphery is in the typical location.•An in-depth heart team approach is crucial to ensure the performance of “in-time” lifesaving treatments in such critical and complex cases. Coronary anomalies are a rare phenomenon. One of the most observed coronary anomalies is the single coronary artery (SCA) originating from one coronary ostium and dividing into the coronary arteries in various configurations,1Angelini P. Coronary artery anomalies: an entity in search of an identity.Circulation. 2007; 115: 1296-1305Crossref PubMed Scopus (569) Google Scholar classified by Lipton’s classification.2Lipton M.J. Barry W.H. Obrez I. Silverman J.F. Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance.Radiology. 1979; 130: 39-47Crossref PubMed Scopus (437) Google Scholar A 38-year-old male patient was admitted to a community hospital with typical signs of non-ST-elevation myocardial infarction (NSTEMI) but without any known comorbidities. Urgent coronary angiography revealed a rare anomaly (incidence of 0.008%3Yamanaka O. Hobbs R.E. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography.Cathet Cardiovasc Diagn. 1990; 21: 28-40Crossref PubMed Scopus (1700) Google Scholar,4Mohanty A. Chandra S. A rare case of 'superdominant' single coronary artery.Indian Heart J. 2015; 67: 389-391Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar) of an SCA, with the left coronary system originating from the right coronary periphery, posterior to the great vessels (Lipton’s classification R-IP, Table 1), and occlusion of the circumflex artery (CX; Fig. 1, A and B ; Video 1 , view video online). A culprit-lesion percutaneous coronary intervention was attempted. However, despite the use of various flexible guidewires and angled microcatheters (90°), CX passage through the left main artery equivalent was not achieved (Video 2 , view video online) and resulted in ST elevation. A prompt control demonstrated a dissection of the left main artery (Figure 1C; Video 3 , view video online). Further interventional approaches were waived, and the patient was transferred for surgical revascularization.Table 1Lipton’s single coronary artery classification2Lipton M.J. Barry W.H. Obrez I. Silverman J.F. Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance.Radiology. 1979; 130: 39-47Crossref PubMed Scopus (437) Google ScholarCriterionCodeDescriptionOstial locationRRight sinus of valsalvaLLeft sinus of valsalvaAnatomic distributionIThe solitary domain vessel follows the course of either a normal right or left coronary arteryIIOne coronary artery arises from the proximal part of the normally located other coronary arteryIIILAD and CX arise separately from a common trunk originating from the right sinus of valsalvaCourse of the transverse trunkAAnterior to the great vesselsBBetween the aorta and the pulmonary arteriesPPosterior to the great vesselsSSeptal type: a part of the route passes through the interventricular septumCCombined type: combination of diverse routesLAD, left anterior descending artery; CX, circumflex artery. Open table in a new tab LAD, left anterior descending artery; CX, circumflex artery. Intraoperatively, coronary dissection was confirmed, whereas the left anterior descending artery and the CX were identified in the typical locations. Coronary revascularization was performed by anastomosis of the left internal mammary artery to the left anterior descending artery, and a saphenous vein graft to the CX was performed using the perfusion-assisted beating heart technique. The postoperative course remained uneventful, and the patient was discharged on the 10th postoperative day. The main issue in SCA remains the dependency on one system, with fatal results in the case of proximal occlusion. Given that the overall incidence of coronary anomalies is very low,3Yamanaka O. Hobbs R.E. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography.Cathet Cardiovasc Diagn. 1990; 21: 28-40Crossref PubMed Scopus (1700) Google Scholar the treatment strategy for acute coronary syndromes in patients with anomalous coronary anatomy remains unclear. In particular, an interventional approach in cases of complex coronary anatomy can result in coronary injury. Given that timing is critical in cases of myocardial infarction, an in-depth—even interhospital—heart team approach is crucial to ensure the performance of “in-time” lifesaving treatments. The authors have no funding sources to declare.