To help understand the following coronary artery angiogram from this patient, a diagram of the right coronary artery and its main branches is shown in the left anterior oblique view. In 60% of patients, the first branch of the right coronary artery is the SA node artery. The acute marginal artery arises at the mid portion of the right coronary artery and supplies the right ventricle. Distally, the artery bifurcates into the posterior descending and the posterolateral branches. The former supplies the inferior wall of the left ventricle and the inferior septum, and the latter usually supplies the posterolateral wall of the left ventricle.
RCA LAO view angio
This is a still-frame of the right coronary angiogram. It demonstrates total occlusion of the proximal portion of the right coronary artery. In the real-time study that follows, note that the distal portion of the right coronary artery and its branches never fill.
RCA LAO view angio - study patient
This is a still-frame of the right coronary angiogram taken at the end of the thrombolytic therapy. Note there is residual stenosis. In the real-time study that follows, note the complete patency of the distal vessel with resolution of the intracoronary thrombus.
Proceed with PCI
A decision was made to perform PCI in this study patient, because of recurrent angina and the residual stenosis.
Inflated balloon still-frame
This is a still-frame showing the guide wire and the contrast filled inflated balloon straddling the stenosis.
Post PCI LAO view angio
This is a still-frame following angioplasty. There is no residual stenosis. The SA node artery is well seen. In the real-time study that follows, note again the normal filling of the right coronary artery and its branches without evidence of any remaining stenosis.
Angioplasty preferred treatment
When appropriate facilities are immediately available during the early phase of acute myocardial infarction, primary PCI is the preferred treatment, as it decreases the incidence of restenosis, but has no impact on short-term outcomes such as mortality, or reinfarction.
In the acute setting, angioplasty can also be used as a rescue or adjuvant procedure for failed thrombolytic therapy and for ongoing ischemia. Adjunctive use of glycoprotein IIb/IIIa receptor blockers increases the success rate and decreases the complications of angioplasty in patients with acute coronary syndromes.
Stent placement diagram
The following diagram demonstrates percutaneous transluminal coronary angioplasty and intracoronary stent placement. A small deflated plastic balloon is passed to an area of coronary artery obstruction with the aid of a guide wire. A stent mounted over the deflated angioplasty balloon is positioned at the site of the lesion.
In the upper panel, a deflated balloon is shown straddling a coronary artery stenosis. In the lower panel, the balloon has been inflated leading to compression and splitting of the coronary artery plaque, with relief of coronary obstruction. Correct stent deployment results in a decrease in elastic recoil of the coronary artery and decreases the incidence of coronary restenosis.
Drug eluting stents further decrease the incidence of in-stent restenosis, but are associated with an increased risk of very late stent thrombosis compared to bare metal stents. The incidence of very late stent thrombsis is 0.6% annually and may persist indefinitely.
Intracoronary stent placement
The angiogram that follows is from another patient. It demonstrates placement of an intracoronary stent in the right coronary artery after a successful angioplasty.