Primarna perkutana koronarna intervencija kod bolesnika sa anomalnim ishodištem leve koronarne arterije iz suprotnog sinusa Valsalva-e i okluzijom glavnog stabla leve koronarne arterije
Sažetak
Uvod. Kongenitalne anomalije koronarnih arterija (KA) otkrivaju se kod oko 5% svih izvedenih koronarografija. Veoma rizičnim se smatraju anomalije kod kojih KA potiču iz suprotnog sinusa (anomalous origination of coronary artery from opposite sinus, ACAOS) Valsalva-e i registruju se kod oko 1% slučajeva. Prikazan je jedinstven slučaj bolesnika sa infarktom prednjeg zida miokarda sa ST elevacijom (ST-elevation myocardial infarction, STEMI) izazvanog okluzijom glavnog stabla leve koronarne arterije (LKA) porekla iz desnog koronarnog kuspisa sa interarterijskim pravcem pružanja, koji je uspešno lečen primarnom perkutanom koronarnom intervencijom (PKI). Prikaz bolesnika. Bolesnik, starosti 46 godina, primljen je kao hitan slučaj zbog kliničkih i elektrokardiografskih znakova za STEMI anteriorne regije. Po prijemu je bio hipertenzivan (150/100 mmHg), u sinusom ritmu
(frekvencija srca 70/min), Killip I. Posle prvog pregleda i uvođenja dvojne antiagregacione terapije bolesnik je podvrgnut urgentnoj koronarografiji. Koronarografija je urađena transradijalnim pristupom. Desna KA koja je bila bez značajnih suženja je lako kanulisana, dok leva koronarna arterija nije mogla da se kanuliše. Pokušano je sa više katetera različitih krivina, ali bez uspeha. Zaključeno je da se radilo o koronarnoj anomaliji i tek sa Multipurpose vodič-kateterom uspešno je kanulisana leva KA čije je ishodište bilo iz desnog koronarnog kuspisa (anomalous aortic origin of the left coronary artery, AAOLCA). Arterija je bila i okludirana u svom distalnom segmentu. Urađena je implantacija dva stenta obložena lekom, ali je kod bolesnika došlo do zastoja koronarnog protoka i kardiogenog šoka. Nakon stabilizacije stanja bolesnika, izvedena je koronarografija uz pomoć kompjuterizovane tomografije kojom je potvrđen AAOLCA, a registrovano je i da postoji potencijalno rizični interarterijski pravac pružanja leve KA. Nakon pregleda izvršenog tehnikom kompjuterizovane tomografije sa jednom fotonskom emisijom (single photon emission computed tomography, SPECT), tokom perioda praćenja, u sledećoj etapi je urađena implantacija stenta u proksimalnu cirkumfleksnu arteriju uz pomoć T and protrusion (TAP) tehnike. Zaključak. Bolesnici sa STEMI i anomalijama KA se relativno retko sreću i predstavljaju izazov za revaskularizaciju, te je poznavanje anatomskih varijeteta neophodno kako bi ovi bolesnici mogli biti adekvatno tretirani primarnom PKI.
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