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Novel use of the AGILISTM-NxT steerable introducer-sheath in a patient with ST-elevation myocardial infarction and anomalous origin of the right coronary artery

A 60-year-old patient with no prior history of cardiovascular disease presented with chest pain, ST-elevation in the inferior leads and was referred to our centre for primary PCI. Angiography of the left coronary artery did not show any stenosis. Initial radial catherisation attempts of the right coronary artery (RCA) failed and an aortic root injection revealed an ectopic anomalous origin of the RCA arising from the left coronary sinus. Further attempts, by femoral approach, to access the vessel origin with conventional coronary guide catheters failed. Finally, a modified mother-andchild approach, by aid of the 8.5 FR medium curl steerable introducer sheath AGILIS-NxT (St. Jude Medical Inc., St. Paul, MI) in combination with a 6 FR internal mammaria artery guiding catheter, enabled selective catherisation (Figure 1: panel A). Angiography revealed a severe stenosis in the proximal segment of the RCA and two drug-eluting stents were successfully implanted (Figure 1: panel B). Subsequent cardiac computer tomography confirmed angiographic findings, showing a good stent result as well as an ectopic origin of the RCA with an intramural course between the aorta and the pulmonary artery. Coronary anomalies are found in approximately 5% of all coronary angiographies. Anomalous location of the coronary artery origin may exceed the range of conventional PCI equipment, demanding novel technical solutions. AGILIS-NxT is an introducer sheath with 8.5 FR inner lumen and a steerable sheath tip allowing for a bi-directional 180 /90 deflection, primarily designed for cardiac ablation procedures. To our knowledge, this is the first case in literature depicting AGILISNxT-facilitated PCI in an acute coronary syndrome patient with anomalous origin of the RCA. The case demonstrates the importance of familiarity with and knowledge of technical aids across the wide spectrum of interventional cardiology. Thinking ‘out-of-the-box’ by using a dedicated cardiac ablation sheath enabled successful PCI and provides an alternative access strategy in patients with coronary anomalies.