Case Report: Successful intravascular ultrasound-guided percutaneous coronary intervention of a single coronary artery with chronic total occlusion and severe calcification using rotational atherectomy

An isolated single coronary artery (SCA) is a rare congenital anomaly, with an incidence of approximately 0.024%. The coexistence of chronic total occlusion (CTO) and severe calcification in a patient with SCA presents substantial procedural challenges during percutaneous coronary intervention (PCI). We report the case of a 52-year-old man with an anomalous right coronary artery (RCA) originating from the left main trunk (LMT), accompanied by proximal RCA CTO, a heavily calcified left anterior descending (LAD) artery, and subtotal occlusion of the left circumflex (LCX) artery. Coronary artery bypass grafting was declined, and a staged PCI was performed under intravascular ultrasound (IVUS) guidance. During the first procedure, stenting of the LCX artery and successful recanalization of the RCA CTO were performed. The second procedure included rotational atherectomy (RA) of the LAD artery, followed by stenting from the LMT to the LAD. Complete revascularization was achieved, and final IVUS imaging confirmed optimal stent expansion. This rare case illustrates that staged, IVUS-guided PCI can be performed safely and effectively in patients with an SCA and complex multivessel disease and that RA is a feasible and safe option for managing severe calcification in this unique anatomical setting.