Anomalies of coronary artery origin at invasive angiography: a prospective study of prevalence, catheter utilisation, access strategy and procedural implications

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BACKGROUND: Anomalies of coronary artery origin are uncommon congenital variants that may pose a challenge to selective engagement at invasive coronary angiography (CAG). Although their prevalence and anatomical spectrum are well described, prospective data on the diagnostic and guide catheter utilisation to engage each anomaly subtype, procedural implications and on the access strategy adopted in current radial-first practice, remain limited. METHODS: We prospectively enrolled 1,850 consecutive adults undergoing invasive CAG, with or without percutaneous coronary intervention (PCI). Anomalies of origin were defined by the modified Angelini classification; intrinsic anomalies and anomalies of termination were excluded. Baseline, angiographic, procedural data - including diagnostic and guide catheter use by subtype; and access strategy were compared between anomaly and non-anomaly groups. RESULTS: An anomaly of origin was identified in 85 of 1,850 patients (4.59%; 95% CI 3.71-5.63%); under a restricted definition that excluded two anatomical variants not consistently classified as anomalies in earlier invasive-angiography series, prevalence was 1.30% (95% CI 0.83-1.92%). The commonest anomaly was ectopic (high or anterior) right coronary artery (RCA) origin from the right coronary cusp (n = 47; 55.3%), followed by separate ostia of left anterior descending (LAD) and left circumflex (LCx) arteries (n = 14; 16.5%) and anomalous LCx from the right coronary cusp or RCA (n = 14; 16.5%). PCI was performed in 52 of 85 anomaly patients (61.2%). Radial access was attempted in 67 patients: 53 (79.1%) completed radially, 14 (20.9%) required crossover to femoral; and 18 were attempted femorally. Anomaly patients required more diagnostic catheters per case (2.20 vs. 1.23), with the greatest burden in crossover cases (3.14 vs. 1.17 catheters); more access crossover (16.5% vs. 5.0%) and more guide catheter changes (44.2% vs. 6.5%; all p < 0.001),. No significant difference in major procedural complications was observed (4.7% vs. 2.7%; p = 0.43); however the study was not powered for rare procedural events.