Multimodality imaging and advanced calcium treatment to facilitate PCI in a rare coronary artery anomaly-case report.

Background: Coronary artery anomalies (CAAs) are a rare congenital condition and represent additional challenges in interventional treatment of coronary artery disease. Case summary: A 76-year-old male, was admitted for elective coronary angiography due to symptoms of typical angina. CT coronary angiography (CTCA) revealed all three coronary arteries arising from the right sinus of Valsalva, where right coronary artery (RCA) and left anterior descending artery (LAD) had common ostium with significant stenosis of ostio-proximal RCA and circumflex artery (CX) coming from a separate one. Percutaneous coronary intervention (PCI) of ostial RCA was planned and intravascular ultrasound (IVUS) in both RCA and LAD was done. Due to extensive calcification, prior to intended PCI, intravascular lithotripsy (IVL) was done. Following IVL and extensive predilatation drug eluting stent (DES) was implanted. Final IVUS was used to confirm optimal stent deployment in proximal RCA and to verify that LAD ostium was not compromised with RCA stent. Six months later, due to angina and positive stress test, repeated coronary angiography revealed a restenosis of the ostial RCA so the lesion was again treated with drug-coated balloon with optimal procedural results. Conclusion: Although rare, CAAs could be associated with coronary artery disease and usually present additional challenge for interventional treatment. Advanced imaging modalities, including CTCA and IVUS, provide good procedural guidance during complex PCI procedures in patients with CAAs.