A 60 year old female with brittle diabetes, mild renal impairment and pulmonary sarcoidosis (FEV1 1.2L) presented with a NSTEMI in late 2024. She had previous crossover stenting from the LAD to the ostial LM in 2021, where an anomalous RCA from the left coronary cusp was noted. This was not haemodynamically significant on physiologic testing at this time.
2. Post initial PCI.mp4

On representation a diagnostic coronary angiogram demonstrated a patent Left Main to Left Anterior Descending artery stent and severe stenosis in the ostial anomalous RCA (Figure 1a).

1. Dx.mp4

Intravascular ultrasound (IVUS) demonstrated severe ostial disease with a “slit-like” appearance and a minimal luminal area (MLA) of 1.36mm² (Figure 2a) with dynamic compression of the proximal RCA. The fibrotic RCA ostium was treated with a 3.5mm Wolverine Cutting Balloon. Real-Time IVUS ostial stenting was performed with a 3.5 x 16mm Megatron deployed. Post stent IVUS showed persistent dynamic compression at the ostium with a minimal stent area (MSA) of 6.53mm² (Figure 2b). A 2^nd 3.5 x 12mm Megatron was deployed over the 1^st stent and post dilated with a 4.0 NC balloon to enhance its radial strength. Final IVUS showed minimal stent compression with an MSA of 8.1mm² (Figure 2c). Final angiogram showed TIMI 3 flow (Figure 1b). 


IVUS 1 - Pre PCI.mp4
IVUS 2 - Post Single Megatron.mp4
IVUS 3 - Post 2nd Megatron.mp4

1) Anomalous RCA with a malignant course can be treated with PCI if surgery is contraindicated. 2) Real-Time IVUS aorto-ostial stenting can be used to stent anomalous coronary arteries accurately. 3) A second stent can be used to increase radial strength and reduce compression if necessary.