left main coronary artery arising from the right sinus of valsalva as a single coronary ostium is an extremely rare anatomic anomaly occurring in approximately 0.06% of angiographic series .
single coronary artery is encountered more frequently with other congenital cardiac malformations such as persistent truncus arteriosus , tetralogy of fallot , transposition of the great arteries , or pulmonary atresia .
some single coronary ostium variants have been reported to carry a significant risk of severe cardiac events including myocardial infarction ( mi ) and sudden cardiac death , especially during exercise .
we present a case of single coronary artery from right sinus with left main coronary artery originating from the same ostium , which underwent successful angioplasty with stenting to right coronary artery through the radial route .
a 60-year - old male was referred to our tertiary care institute for coronary angiography .
patient suffered acute coronary syndrome ( acs ) - inferior wall mi 3 days prior to admission in our institute . he was thrombolysed with streptokinase at a peripheral center and referred to our institute on the 4 day post thrombolysis in view of post mi angina .
transthoracic echocardiogram showed regional hypokinesia in the right coronary artery ( rca ) territory with adequate left ventricular ejection fraction .
coronary angiography ( cag ) by radial approach using tiger 5f catheter ( terumo corp . ,
cag revealed blunt left sinus , with no artery originating from the left sinus [ figure 1 and video 1 ] .
right coronary artery originated from the usual location and a long left main coronary artery arose from the same ostium [ figures 2 , 3 and video 2 ] .
we exchanged the tiger catheter with judkin 's right coronary catheter ( medtronic , inc . ,
minneapolis , mn , usa ) as it was not possible to selectively cannulate the ostium with the tiger catheter .
there was significant tubular stenosis in the mid - rca region and non - critical plaque in the proximal left coronary artery ( lca ) [ figures 2 , 3 and videos 2 , 3 ] .
as it is important to know the course of anomalous coronaries before any intervention , ct angiogram was done which revealed retroaortic course of the left coronary [ figures 4 and 5 ] .
it was decided to do percutaneous coronary intervention ( pci ) with stenting to the mid - rca in view of post mi angina and was performed on the 5 day post thrombolysis .
rca was selectively cannulated with judkin 's right coronary catheter ( medtronic , inc . ) .
the lesion was crossed with 0.014  190 cm bmw wire ( abbott vascular , santa clara , ca , usa ) and predilated with 2.5  12 mm maverick balloon ( boston scientific , florida , usa ) [ figure 6 and video 4 ] . during predilatation , guide sucked in the vessel and pressure damping was noted due to obstruction of supply to the left coronary and this was managed by meticulous decannulation and avoiding deep intubation . a 3.25  33 mm xience v stent ( abbott vascular , florida , usa ) was deployed at 14 atm [ figure 7 and video 5 ] .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
coronary angiography - ap view fluoroscopy shows blunt left sinus ( arrow ) with no coronary origin .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
coronary angiography - right anterior oblique angiographic view shows both right and left coronaries originating from the right sinus ( arrow ) .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
coronary angiography - lateral angiographic view shows both rca and lca originating from same ostium ( arrow ) .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
coronary angiography - right anterior oblique angiographic view shows both right and left coronaries originating from the right sinus .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
coronary angiography - lateral angiographic view shows both rca and lca originating from same ostium .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
ct coronary angiography - ct image with 3d reconstruction shows retroaortic course of lca ( arrow ) .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
coronary angiography shows left anterior oblique fluoroscopic view of rca during predilatation ( arrow ) .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
coronary angiograph shows left anterior oblique fluoroscopic view of rca during stent deployment ( arrow ) .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
60-year - old male with acs - inferior wall mi post thrombolysis and post mi angina .
coronary angiography - left anterior oblique angiographic view of rca shows end result post stenting ( arrow ) .
60-year - old male with acs - inferior wall mi , post thrombolysis and post mi angina .
coronary angiography - left anterior oblique angiographic view of rca shows end result post stenting .
lipton et al . , classified coronary variations based on origin and anatomical course relating to the ascending aorta and pulmonary trunk .
type l represents an rca originating from the left main stem and type r indicates that the coronary artery originates from the rca .
class ii indicates one coronary artery arising from the proximal part of the normally located opposite coronary artery . in class iii , the left anterior descending ( lad ) and left circumflex ( lcx ) arise separately from the proximal part of a normal rca .
classes ii and iii are then designated as anterior ( type a ) to pulmonary artery or posterior ( type p ) to aorta , or interarterial ( type b ) if it courses between the ascending aorta and the pulmonary trunk .
type b morphology has been associated with a high risk of clinical consequences when associated with an intramural course .
angelini et al . , proposed a slightly different classification according to the anatomical course within the interventricular sulcus and atrioventricular groove , as well as the location of penetrating side branches . according to lipton 's classification ,
our patient had r ii p subgroup ( single coronary artery from the right sinus with lca arising from the proximal part of rca and a posterior course to aorta ) .
lipton 's classification has been modified by others , adding to this classification the  s
though there are several case reports of pci in single coronary artery , most are through the femoral route . to the best of our knowledge ,
we did not have much difficulty during pci as we were using right radial artery approach and judkin 's right catheter .
other catheters like internal mammary artery ( i m a ) , multipurpose , and amplatz left ( al ) can also be used according to the situation .
the present case merits mention because of several points : 1 ) intervention in a single coronary artery through radial approach has been rarely reported and in type r ii , it is all the more rare .
2 ) ct 3d reconstruction is a useful tool to understand the ostial configuration and course of anomalous coronary .
3 ) radial pci is as good as femoral pci for anomalous coronaries , provided good hardware is selected and operator has experience in radial interventions .
4 ) meticulous attention should be given to pressure damping while doing pci in cases with both coronaries originating from single ostium .
5 ) we should take non - selective shoot if there is no coronary originating from either sinus ( left / right ) .
 we present percutaneous coronary intervention ( pci ) using radial approach in a rare case of single coronary artery originating from the right sinus . although these anomalies and stenosis of anomalous vessels have been described previously , treatment of atherosclerotic lesions by pci 
 has rarely been reported . 
 there is a definite procedural risk during pci in patients with a single ostium because dissection with the guiding catheter would result in a catastrophic event . 
 additionally , technical difficulties may occur due to the ostial configuration and course of the branch to be stented . 
 the patient suffered an acute coronary syndrome - inferior wall stemi , and was thrombolysed elsewhere within a window period of 4 h. he had post myocardial infarction ( mi ) angina and was referred to our center after 3 days of thrombolysis . 
 we present this technically challenging and rare case in which pci of right coronary artery was performed through the radial route . 