Catheter selection in patients with anomalous coronary arteries using coronary computed tomography angiography

Abstract Background Anomalous aortic origins of a coronary artery (AAOCAs) are increasingly diagnosed with the expanded use of coronary computed tomography angiography (CCTA). While the optimal management of patients with atherosclerotic coronary disease and AAOCA is controversial, invasive angiography remains widely used for diagnosis and treatment. However, AAOCAs are challenging to engage and have been associated with increased fluoroscopy time, contrast use, and adverse events. To date, evidence on the evaluation of AAOCA using noninvasive imaging to guide catheter selection remains scarce. Purpose We aimed to determine the engagement success of various types of catheters based on novel proposed CCTA-based locations of AAOCA ostia (Fig. 1A-B) among patients undergoing invasive angiography. Methods We performed an exploratory retrospective analysis investigating the imaging and procedural characteristics of patients with AAOCAs evaluated by both CCTA and invasive angiography at a large tertiary care center. Our primary interest was the type of catheter utilized for the successful engagement of an AAOCA based on its anatomic location. Results Between January 2019 and October 2024, 69 patients with AAOCAs demonstrated by CCTA who underwent invasive angiography were included in the analysis. Patients were on average 67.8 years old, were mostly male (60.9%), and often had pre-existing chronic kidney disease (20.3%). The majority (66.7%) of AAOCAs were anomalous RCA originating from the left sinus of valsalva (Fig 1C), had an acute angle take-off (79.7%), and had an interarterial course (55.1%). Selective engagement and angiography was successful in 73.1% and 98.6% of patients, respectively, with a mean of 2.7 catheters, total contrast of 98.1 ml, and fluoroscopy time of 15.7 minutes. Among right AAOCAs, Judkins left (JL) catheters were intermittently successful in engaging right AAOCAs from the left sinus of Valsalva, specifically if located between the midline and the left main coronary artery ostium (location C; Fig. 2). Amplatz type catheters (AL, AR), extra support guide catheters (EBU, VL), and Judkins right (JR) catheters were occasionally necessary for selective engagement, specifically for ostia originating at the midline of the left and right cusps (location D) or 10 mm above the sinotubular junction (location A). A 30% discordance was observed between CCTA and angiographic characterization of right AAOCA originating from the left sinus of valsalva. Among left AAOCAs originating from the right sinus, both JR and Amplatz type catheters (AL, AR) were successful in selective engagement. Conclusion Engaging AAOCAs during invasive angiography remains challenging due to their aberrant characteristics, frequently resulting in the use of multiple catheters as well as increased contrast use and fluoroscopy time. CCTA may be a useful adjunct for pre-procedural planning of catheter selection prior to invasive angiography.