Role of computed tomography-guided optimal fluoroscopic viewing angle for aberrant right coronary artery engagement

We report the case of a 26-year-old male presenting with exertional chest pain who was found to have an anomalous right coronary artery (RCA) arising from the left coronary sinus with an interarterial course on coronary computed tomography angiography (CCTA). Given the presence of symptoms and high-risk anatomical features, the patient was referred for surgical unroofing, and invasive coronary angiography was performed for preoperative assessment. Pre-procedural CT analysis was used to derive patient-specific fluoroscopic projections by aligning the aortic annulus and aberrant RCA ostium S-curves, identifying an optimal angiographic view (right anterior oblique [RAO] 16°, caudal [CAUD] 16°). During coronary angiography, use of this CT-derived projection enabled first-attempt selective engagement of the anomalous RCA using a Judkins Right 4 catheter without the need for catheter exchange or extensive manipulation. This case highlights the utility of CT-guided fluoroscopic planning in facilitating efficient and safe engagement of anomalous coronary arteries, with potential to reduce procedural complexity, contrast use, and complications.