Percutaneous coronary intervention to left anterior descending artery/right coronary artery bifurcation: this is not a typo! A case report

BACKGROUND: Anomalous origin of the right coronary artery (RCA) is a rare congenital anomaly. A single coronary artery arising from the left sinus of Valsalva, with the RCA originating from the left anterior descending artery (LAD), is extremely rare. We report the case of an anomalous origin of the RCA from the mid LAD with a significant bifurcation lesion, in the setting of an acute coronary syndrome, endangering both the RCA and LAD territories. CASE SUMMARY: An 85-year-old female presented with a non-ST elevation acute coronary syndrome. Transradial coronary angiography revealed an anomalous origin of the RCA arising from the mid LAD beyond a large first septal perforator. There was significant stenosis involving anomalous RCA/LAD bifurcation classified as Medina 1, 1, 1. Following discussion at heart team meeting, she underwent successful percutaneous coronary intervention. The LAD/RCA bifurcation was treated using a two-stent culotte technique without any complications. Computed tomography coronary angiogram was performed which confirmed a benign course of the anomalous RCA anterior to aorta and pulmonary artery. DISCUSSION: This anomaly poses a significant challenge in revascularization due to the large area of myocardium subtended by the LAD and RCA and usually an acute angle of bifurcation. Moreover, CTCA can be useful to ascertain the course of anomalous RCA.