Unroofing of an Anomalous Right Coronary Artery

This article is part of CTSNet’s Guest Editor Series, Coronary Arterial Anomalies—Pediatric and Adult Congenital. CTSNet Senior Editor Dr. Sameh Said invited both pediatric and adult cardiac surgeons from around the world to contribute clinical videos on various coronary arterial anomalies and different surgical techniques that are used to manage them.

This video demonstrates unroofing of an anomalous right coronary artery in a 60-year-old woman who presented with angina. The coronary angiography showed an anomalous origin of the right coronary artery from the left coronary cusp. This was confirmed on gated coronary CT, which showed it arising from the left sinus of Valsalva with a slit-like orifice and a significant intramural course. 

The decision was made to repair the RCA by unroofing the anomaly. A median sternotomy was performed as was routine cannulation for cardiopulmonary bypass. Dissection began between the great arteries to identify the right coronary artery as it exited from the aorta. Cardioplegic arrest was then achieved, and the RCA was isolated at the point of exit from the aorta by placing a Silastic loop around it. 

An aortotomy was performed just superior to the sinotubular junction, extending it to the left somewhat superiorly. The orifice of the RCA was identified and a metal probe was inserted, which clearly identified that the track ran superior to the commissure between the left and right coronary sinuses. 

Careful assessment was performed to establish the length of the intramural segment. An unroofing with the probe as a guide began. The importance of establishing the length of the intramural segment is to avoid being overly aggressive with the unroofing, which could lead to bleeding externally. The roof of the tunnel was excised as the unroofing proceeded, and stay sutures providing the necessary traction. Once the unroofing had been done, the intima of the aorta and the coronary artery were tacked together using 6-0 Prolene suture. This eliminates the risk of dissection when the aortic root is pressurized. Typically, approxiamtely six to eight of these tacking sutures will suffice. The final probe confirmed that the orifice was widely patent, and the aortotomy was closed in the usual way. The cross-clamp was rreleased,and the RCA was immediately inspected as it exits the aorta to ensure that there was no bleeding. This would occur if there was overly aggressive unroofing performed from within. 

Transit time flow measurements were performed, and confirmed that there was excellent flow in the RCA. The patient was weaned from cardiopulmonary bypass, decannulated, and routine closure was performed. The patient was discharged on postoperative day four, and coronary CTA performed six weeks later confirmed that the anomaly had been corrected. 

The advantage of unroofing is that it relocates the functional orifice to the appropriate sinus and enlarges the orifice considerably. Also, it eliminates the intramural portion of the anomalous artery and eliminates the segment that lies between the great arteries. Pitfalls include aortic incompetence from damage to the commissure, dissection if the layers are not tacked, and overly aggressive unroofing leading to external bleeding. 

References

1. Bibevski S, Ruzmetov M, Turner II, Scholl FG. ANOMALOUS AORTIC ORIGIN OF RIGHT CORONARY ARTERY: OUTCOMES OF SURGICAL AND NON-SURGICAL TREATMENT. Ann Thorac Surg. 2021 Dec 7:S0003-4975(21)02024-5. doi: 10.1016/j.athoracsur.2021.11.008. Epub ahead of print. PMID: 34890570.
2. Gharibeh L, Rahmouni K, Hong SJ, Crean AM, Grau JB. Surgical Techniques for the Treatment of Anomalous Origin of Right Coronary Artery From the Left Sinus: A Comparative Review. J Am Heart Assoc. 2021 Nov 16;10(22):e022377. doi: 10.1161/JAHA.121.022377. Epub 2021 Nov 2. PMID: 34726074; PMCID: PMC8751967.

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