This is a case of a 39 year-old Filipino female, hypertensive, who initially presented with sudden severe chest pain. She then sought emergency consult at our institution with a normal initial 12-lead ECG and high sensitivity troponin I. On the third hour of consult, she went into pulseless ventricular tachycardia. Advanced cardiac life support was performed with return of spontaneous circulation after 5 min. Repeat12-lead ECG showed anterior wall ST elevation. Catheterization lab was activated.

12 Lead ECG:  Sinus Rhythm, Normal Axis, Anterior Wall ST elevation.High Sensitivity Troponin I: 7.8 ng/LNT-pro BNP: 134 pg/ml

Coronary angiogram revealed an absent left main artery with a 95% ostio-proximal stenosis of the left anterior descending artery (LAD) and an 80% ostio-proximal stenosis of the left circumflex artery (LCX). Intravascular ultrasound (IVUS) of the LAD lesion showed mixed plaque with a distal reference cross-sectional area (CSA) of 8.5 mm2, a minimal luminal CSA of 5.26 mm2 and confirmed an absent left main artery. 

Culprit vessel stenting of the LAD was done using a 3.5 x 15 mm stent, with 2 stent struts exposed at the aortic lumen. IVUS of the LCX showed mixed plaque with a distal reference CSA of 6.01 mm2 and a minimal luminal CSA of 3.4 mm2. Plain old balloon angioplasty of the LCX was done. Post PCI angiogram showed no residual stenosis in the LAD with TIMI III flow but with a residual 90% stenosis in the LCX ostium. Completion stenting of the LCX was deferred due to cardiogenic shock. The following day, she underwent completion PCI with stenting of the LCX. Attempts to distalize a guidewire though the native LCX ostium failed. Hence, a workhorse guidewire was passed through the proximal LAD stent struts and subsequently distalized into the LCX.A 1.5 x 15 mm balloon was used to open the LAD stent struts. Through this, a3.0 x 18 mm stent was deployed at the ostio-proximal LCX, with 2 stent struts protruding within the previously placed LAD stent. A workhorse guidewire was used to cross the LCX stent struts and was distalized into the LAD. Kissing balloon inflation with a 4.0 x 12 mm balloon at the LAD and a 3.0 x 12 mm balloon at the LCX was done. IVUS of the LCX showed a minimal stented cross-sectional area (MSA) of 5.2 mm2. Post procedural angiography showed no residual stenosis with TIMI grade III flow. The patient was discharged stable and improved. 

In conclusion, congenital anomalous coronary arteries may present with life threatening complications and management of these patients should be individualized depending on the anatomy, condition on presentation, and diagnostic and imaging findings. Decision to do a culprit only versus a complete PCI strategy should be done with the consideration of the patient’s current state, utilizing available tools such as the intravascular ultrasound.