Virtual Reality-Guided Simulation for Percutaneous Coronary Intervention in a Patient with Anatomical Anomalies: A Case Report

Introduction

A rotational atherectomy (RA) for the left circumflex (LCX) ostium is challenging due to the tortuous anatomy, acute angulation, and variable vessel size compared to other lesions [1]. The appropriate positioning and coaxiality of the guide catheter (GC) are key factors for safely performing RA. A right-sided aortic arch with aberrant left subclavian artery is a rare variant of vascular anatomy [2]. The selection of a percutaneous coronary intervention (PCI) approach site can be restricted in patients with a variant of the normal vascular anatomy. Recently, the efficacy of virtual reality (VR)-guided GC simulation for patients with anatomical anomalies using cardiac computed tomography (CT) has been reported [3]. We report here that the VR-guided GC simulation was effective for pre-operative planning for complex PCI for a patient with a right-sided aortic arch.

Case Report

A 55-year-old man with hypertension, dyslipidemia, diabetes mellitus, and history of old anterior myocardial infarction was admitted to our hospital for chest pain. An electrocardiogram showed negative T waves in the I, aVL V5, and V6 leads (Figure 1). A transthoracic echocardiogram showed a global reduced left ventricular wall motion. His left ventricular ejection fraction (LVEF) was 25%. Elective coronary angiography (CAG) was performed via the right femoral artery due to poor palpation of bilateral radial arteries. CAG showed an ostial calcified lesion of LCX (Figure 2). The patient’s syntax score was low (9.0). CT showed right-sided aortic arch with stenosis of the left subclavian artery from the Kommerell diverticulum at the distal part of the aortic arch (Figure 3). Therefore, approaching from the left upper limb was deemed impossible. We simulated the appropriate guide catheter and the approach site for PCI by VR in the manner previously reported [3] (Video 1). The simulation of Hyperion Amplatz Left (AL) 1.5 (Asahi Intecc, Aichi, Japan) from the right upper limb approach was considered the best selection for engagement and coaxiality because the GC passes posterior to the greater curvature of the ascending aorta (Figure 4A, 4B, 4E). However, when approaching from the lower limb, the GC passes greater curvature of the ascending aorta, making the engagement of the GC difficult (Figure 4C–4E). It took about 10 minutes to perform these VR simulations. PCI was performed via the right brachial artery with Hyperion AL1.5, 7-French, as in the VR simulation (Figure 5A). We used an intra-aortic balloon pump because of the complexity of PCI in patients with low LVEF. We performed RA using an RA system (Rotalink Plus 1.5 mm and 2.0 mm, Boston Scientific Corporation, Natic, MA, USA) with RotaWire Floppy (Boston Scientific Corporation, Natic, MA, USA) (Figure 5B). Then, we performed balloon angioplasty using a cutting balloon (Wolverine 3.0/10 mm, Boston Scientific Corporation, Natic, MA, USA). The lumen area was enlarged, and we used a drug-coated balloon (SeQuent® Please NEO 3.0/20 mm, B. Braun Company, Melsungen, Germany) for this lesion because of avoiding stent placement to the left main trunk. Finally, we acquired a successful result (Figure 5C).

Discussion

There are several reasons why RA to LCX ostial lesions is difficult. The risk of vessel perforation is higher in RA to LCX due to the tortuous anatomy, acute angulation, and variable vessel size compared to other lesions [1]. Appropriate selection of GC is important for successful RA to LCX ostial lesion. The engagement and coaxiality of GC differ greatly by approach site because GC passage lines are different. In this case, the tip of the GC needed to be oriented in a more LCX direction and strengthen the backup because the left main trunk and LCX bifurcation angle was large. The GC passage lines from the right upper limb or the lower limb were much different (Figure 4E). Hyperion AL 1.5 from the right upper limb approach was good for this complex PCI. We previously reported preprocedural planning using a three-dimensional (3D) printed model for PCI in an anomalous coronary artery [4]. 3D-printed models can be extremely beneficial because it is difficult to engage the GC in PCI for anomalous coronary arteries. However, creating a 3D model takes time and effort. On the other hand, the VR-guided GC simulation takes several minutes to simulate and identify the most suitable GC for the patient although cardiac CT prior to PCI is required like creating a 3D model [3]. To the best of our knowledge, this is the first report of VR-guided PCI for a patient with a right-sided aortic arch. Furthermore, VR-guided GC simulation before PCI may be effective for patients with aberrant coronary artery or after transcatheter aortic valve implantation. Because there are concerns that the engagement of GC is more difficult in these patients, requiring more procedure time, increasing the number of GCs, and increasing the probability of complications by unstable GC. VR-guided GC simulation seems to have great potential in terms of safety and procedure success rates and medical cost of GC selection.

Therefore, accumulation of clinical data and evaluation of efficacy will be important. Combined with artificial intelligence, we may soon know the appropriate approach site and guide catheter at the cath lab in the future.

Conclusions

We successfully performed PCI for an ostial calcified lesion of LCX in a patient with a right-sided aortic arch. We suggest that use of VR-guided GC simulation can be a good option in patients with complex lesions or rare anomalies.