Right coronary artery takeoff plane and implications for brachiocephalic interventions and next generation transcatheter aortic valve intervention embolic protection devices.

Objectives: The authors hypothesized that the origin of the right coronary artery (RCA) is a direct continuation of the major aortic arch branches (MAAB) takeoff plane, which may have implications for brachiocephalic interventions and next generation transcatheter aortic valve intervention (TAVI) embolic protection devices (EPDs).

Methods: In this single-center, retrospective, cross-sectional study, the authors analyzed computed tomographic angiography (CTA) images from 92 patients undergoing TAVI evaluation to determine the spatial relationship between the origin of the RCA and the MAAB takeoff plane. Patients with prior cardiothoracic or aortic interventions and those with anomalous RCA origin were excluded. Using double oblique imaging planes, the authors assessed whether the RCA and MAAB takeoffs were visualized within the same sagittal plane.

Results: The mean age of the patients was 76.4 years; 52% were female. Most patients had hypertension (90%), coronary artery disease (65%), or a history of smoking (47%). The RCA origin aligned with the forward and downward continuation of the MAAB plane in 77.1% of the patients.

Conclusions: This novel anatomical relationship, not previously described in literature, may be clinically useful during cardiac catheterization when cannulating brachiocephalic vessels to visualize right and left internal mammary arteries and during brachiocephalic interventions such as subclavian and carotid stenting. Additionally, the findings suggest that some third generation TAVI EPDs with anchoring probes resting in the aortic root may lie in close proximity to the RCA ostium. This proximity could hinder urgent RCA cannulation during TAVI procedures. As new EPD designs gain traction globally, it is essential for TAVI operators to understand this anatomical nuance.