A 66-year-old man presented with substernal chest pain of one hour’s duration and electrocardiographic evidence of acute inferior wall ST-segment elevation myocardial infarction. He underwent emergency coronary angiography that showed total occlusion of the mid right coronary artery (RCA) (fig. 1A) just beyond the origins of a right ventricular branch (RVB) and the sinus node artery (SNA), and significantly obstructive lesions in the distal left main coronary artery, the proximal left anterior descending artery and the obtuse marginal artery. Collateral circulation (Rentrop grade II) to the distal RCA branches from the left coronary artery was also noted (fig. 1B). Initial angiography of the RCA also showed a peculiar, faintly visualised vessel in an area corresponding to the acute margin of the heart, which was initially assumed to be the distal RCA being collateralised from the RVB (
moving image 1)
1. During subsequent percutaneous coronary intervention, the guide wire tracked up the distal RCA outside the faintly visualised vessel, which was seen as comprising two branches and a drain point (fig. 1C;
moving image 2 and moving image 3); it was thus recognised as a coronary vein. Percutaneous coronary intervention was completed with delivery of three bare-metal stents across the mid RCA lesion and two bare-metal stents across a lesion from the distal RCA to posterior left ventricular branch. Final RCA angiography disclosed Thrombolysis in Myocardial Infarction (TIMI) grade III flow, occlusion of the RVB, subocclusion of the SNA and disappearance of the previously seen coronary vein (fig. 1D and
moving image 4). The patient had an uneventful hospital course and was referred for surgical revascularisation of the left coronary artery lesions.
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