Primary Percutaneous Coronary Intervention in Single Ostium Coronary Arteries: Challenges and Considerations

Coronary anomalies occur in a very small proportion of the general population. One such anomaly is a single ostium coronary artery (SOCA). Primary percutaneous coronary intervention (PCI) in SOCA can pose significant challenges due to anatomical complexity or hardware selection. We present the case of a 59-year-old man who presented to the emergency department with typical chest pain and electrocardiographic evidence of inferior wall ST-segment elevation myocardial infarction (STEMI). The patient subsequently underwent coronary angiography via a radial approach. Angiography revealed the left main coronary artery (LMCA) giving rise to a dominant right coronary artery (RCA), anatomically classified as Shirani-Roberts Type 1B. The distal RCA was sub-totally occluded just proximal to the crux. The patient subsequently underwent successful primary PCI to RCA. Computed tomography coronary angiography (CTCA) is advised in anomalous origin RCA to delineate malignant anatomy. In our case, this was not performed due to the financial constraints of the patient, leaving the exact course of the RCA undetermined. Our case report highlights the importance of operator expertise, catheter selection, and individualized strategies for managing coronary anomalies. It emphasizes that early recognition and tailored procedural planning are critical to optimizing outcomes in patients with SOCA presenting with acute coronary syndromes.