Percutaneous revascularization in a patient with anomalous origin of left main coronary artery

Anomalous origin of the coronary artery from opposite coronary sinus is infrequently observed during coronary angiography. Percutaneous coronary intervention (PCI) of anomalous coronary artery is technically difficult and challenging. It requires appropriate selection of guide catheters for adequate stability, coaxial alignment and backup support during the intervention. We hereby report a rare case of anomalous origin of left main coronary artery (LM) from the right coronary sinus, having a retro-aortic course to the left side before its bifurcation into left anterior descending (LAD) and circumflex artery. The 59-year-old man had successful PCI of atherosclerotic LAD lesions. A 64-slice Multi-Detector Computed Tomography (MDCT) performed at 4 years of follow-up demonstrated patency of coronary stents and also delineated the origin and course of the anomalous LM. The case illustrates the rarity of anomalous LM, and describes technical issues during PCI and the role of MDCT in coronary anomaly imaging.     

Visualization of coronary artery anomalies by contrast-enhanced multi-detector row spiral computed tomography

BACKGROUND: We investigated the potential of 16-slice multi-detector row spiral CT (MDCT) with retrospective ECG-gating for evaluation of coronary artery anomalies. METHODS: A total of 35 patients (23 men, 12 women, 19-81 years) in whom anomalous coronary arteries had been detected by invasive coronary angiography underwent MDCT (Sensation 16, Siemens, Germany). During one breathhold, a contrast-enhanced (90 ml, 5 ml/s) volume data set of the heart was acquired (16x0.75mm collimation, gantry rotation 375 ms). Images were reconstructed with a slice thickness of 1.0 mm in 0.5-mm intervals using retrospective ECG-gated reconstruction. The 35 data sets and 80 data sets of patients with angiographically normal coronary anatomy were analysed in random order concerning the origin and course of the coronary arteries. The results were compared to invasive coronary angiography. RESULTS: All patients with coronary artery anomalies and all controls with normal coronary anatomy were identified by MDCT. In addition, the origins and course concerning their anatomical relationship to adjacent cardiac structures were visualized in all patients, including right-sided origin of the left main (n=10), left anterior descending coronary artery (n=4) or left circumflex coronary artery (n=10); left-sided origin of the right coronary artery (n=6); four coronary fistula to the pulmonary artery (two from the left anterior descending, one from the right coronary artery, one from the left main), and one fistula from the circumflex coronary artery to the left atrium CONCLUSIONS: The study demonstrates that MDCT is a reliable noninvasive technique to identify and define anomalous coronary arteries and their course.     

Origin of all major coronary arteries from left sinus of Valsalva as a common coronary trunk: single coronary artery--a case report

Coronary anomalies are divergent and can occur in up to 1% to 2% of patients. The most common of these anomalies is separate ostia of the left anterior descending and left circumflex arteries, followed by origin of the circumflex coronary artery from the right coronary artery and the left coronary artery from the right sinus of Valsalva, either as a separate ostium or as a part of single coronary artery. Anomalous origin of right coronary artery from the left sinus of Valsalva with a separate ostium or from the left main coronary artery is very rare. These coronary anomalies may be incidentally diagnosed on routine angiography or may present with myocardial ischemia, infarction, or sudden death. A case is described in which all 3 coronary arteries were originating from the left sinus of Valsalva as a common trunk (single coronary artery), which trifurcated to left anterior descending, left circumflex, and right coronary artery.     

An unusual combination of coronary arterial and systemic venous anomalies-clinical implications

A 57-year-old male underwent coronary angiography for exertional angina which showed two left anterior descending coronary arteries (LAD)--a short LAD from the left coronary sinus terminating in the proximal Anterior Inter-Ventricular Sulcus (AIVS), a long LAD from the proximal right coronary artery entering the distal AIVS and an anomalous left circumflex artery from the right coronary sinus. In addition, he also had absent right superior vena cava and a persistent left superior vena cava entering the coronary sinus.     

A rare type of dual left anterior descending artery distribution demonstrated by multislice cardiac computerized tomography in a patient with anterior wall infarction

Dual left anterior descending coronary artery (LAD) distribution with either of the vessels originating from the left main coronary artery (LMCA) and the right aortic sinus of Valsalva is an extremely rare coronary artery anomaly. Here we discuss a 45-year-old male who presented with non-ST-elevation anterior wall myocardial infarction due to near-total occlusion of the LAD immediately after its origin from the LMCA. The distal interventricular septum was supplied by an additional LAD arising from the right aortic sinus with a long septal course. The anomalous origin and septal course of the latter vessel were confirmed with multislice cardiac computerized tomography. The binary distribution of the LAD limited the extent of ischemic insult to the anterior wall in this case.     

Percutaneous Coronary Intervention for Acute Myocardial Infarction in a Single Coronary Artery Anomaly

We report on a case of an adult male patient with previously unknown coronary anomaly and acute myocardial infarction in the territory of the left anterior descending artery (LAD). The coronary angiography showed a single coronary artery with intertruncal course, arising from the right coronary sinus, and thrombotic occlusion of the LAD. Successful transradial percutaneous coronary intervention was done with implantation of an intracoronary stent in the occluded artery. The postprocedural course was complicated by ventricular tachycardia, congestive heart failure, and mild transient renal failure. In conclusion, transradial percutaneous coronary intervention is safe and feasible in rare coronary artery anomalies even in an emergent setting. The finding of an anomalous coronary artery should not be a reason to decline performing coronary intervention. Copyright © 2009 Wiley Periodicals, Inc.     

Anomalous left anterior descending, absent circumflex and unusual dominant course of right coronary artery: a case report--R1

A 40-years-old female presented with atypical chest pain. Selective coronary angiography revealed separate osteal origin of anomalous left anterior descending (LAD) and normal origin of right coronary artery (RCA) from right anterior coronary sinus. LAD had a septal course. Left circumflex (LCx) was absent. RCA, a dominant vessel, continued beyond the crux, along the entire length of atrioventricular groove as circumflex artery. There was no myocardial ischemia on stress thallium. As per our knowledge, this type of combination of anatomical variation of coronary circulation has not been described in the literature.     

Isolated single coronary artery with dual right coronary artery distribution. A rare anatomical variation

We present the case of a 76-year-old patient in whom coronary angiography, performed due to non-ST-segment elevation myocardial infarction, revealed an isolated single coronary (SCA) artery with dual right coronary artery (RCA) distribution. One RCA arose from the mid segment of the left anterior descending (LAD) artery and followed a prepulmonic course to the right, while the other RCA arose as the terminal extension of the left circumflex artery beyond the crux cordis. This is the second reported case of the combination of these two variants of SCA and the first such case in which the LAD-derived RCA originated as a single branch. Furthermore, this is the first report presenting a sinus node artery with origin from an ectopic LAD-connected RCA. The clinical implications of this rare coronary artery pattern are discussed.     

Isolated single coronary artery with dual right coronary artery distribution

We present the case of a 76-year-old patient in whom coronary angiography, performed due to non-ST-segment elevation myocardial infarction, revealed an isolated single coronary (SCA) artery with dual right coronary artery (RCA) distribution. One RCA arose from the mid segment of the left anterior descending (LAD) artery and followed a prepulmonic course to the right, while the other RCA arose as the terminal extension of the left circumflex artery beyond the crux cordis. This is the second reported case of the combination of these two variants of SCA and the first such case in which the LAD-derived RCA originated as a single branch. Furthermore, this is the first report presenting a sinus node artery with origin from an ectopic LAD-connected RCA. The clinical implications of this rare coronary artery pattern are discussed.     

Anomalous origin of posterior descending artery from left anterior descending in the presence of a diminutive right coronary artery: diagnosed by ECG gated multi-detector CT

Coronary anomalies are easily detected on ECG gated multi-detector CT which has shown to be superior to conventional angiography is demonstrating their origin and course. We present an unusual case of posterior descending artery arising as the continuation of the left anterior descending artery (LAD) in the presence of a diminutive right coronary artery (RCA). The LAD crossed over the apex and continued its course to the base of the heart in the posterior interventricular groove as PDA. The RCA, although normal in origin, was diminutive and terminated on the lateral wall of the right ventricle. This anomaly has been rarely reported and the previous cases have all been conventional angiographic findings.     

Non-visualized left anterior descending artery revealed on selective conus artery catheterization

Cardiac catheterization of a man with severe angina and anterior ischemia on exercise testing with perfusion imaging demonstrated normal anterior wall motion on resting left ventriculography, but failed to visualize the left anterior descending (LAD) or conus artery on left and right coronary angiography. Selective contrast injection of a large conus artery originating from a separate ostium in the right aortic sinus demonstrated extensive collateral circulation to an LAD occluded at its origin from the left main coronary artery, thus providing essential information for subsequent patient management.     

Report of a new anomaly of the left anterior descending artery: type VI dual LAD

A 48-year-old man with past medical history of coronary artery disease, previous angioplasty, hyperlipidemia, and generalized anxiety disorder presented with atypical chest pain. Coronary angiography and CT angiography revealed a variant dual left anterior descending (LAD) coronary artery not previously described. Spindola-Franco et al. have categorized dual LAD into four angiographic subtypes based on the origin and course of both a short- and a long branch of the LAD. Additionally, Manchanda et al. have described a novel variant of dual LAD with the short- and long LAD originating directly from the left and right coronary sinuses, respectively (Type V, see Table I). In the case presented, the long LAD arises from the right coronary artery and follows a unique route underneath the right ventricular outflow tract in the interventricular septal area to the anterior interventricular groove. We propose that this anatomy represents a new variant of dual LAD (Type VI).     

Complex coronary artery anatomy in a patient with prolapsing left atrial myxoma

The case of an asymptomatic patient with prolapsing left atrial myxoma, in whom preoperative coronary angiography revealed a rare coronary artery anatomy in the absence of atherosclerotic obstructive disease, is presented. There was a type?IV dual left anterior descending (LAD) artery with intraseptal course of the right aortic sinus-connected (long) LAD artery and an ectopic left circumflex artery originating from the right aortic sinus and having a retroaortic course. The patient underwent successful surgical excision of the mass which was confirmed by histology to be cardiac myxoma. This particular coronary artery anatomy has only been described once, and this is the first reported case of its combination with cardiac myxoma. This report highlights the importance of differentiating between the possible courses of such ectopic coronary arteries. The angiographic signs which enabled differentiation of the intraseptal course of the long LAD artery from the malignant interarterial course with which it is frequently confused are presented.     

Congenital coronary anomalies of origin and distribution in adults: a coronary arteriographic study

BACKGROUND: Coronary anomalies should be recognized to avoid problems during coronary intervention and cardiac surgery. METHODS AND RESULTS: We retrospectively reviewed 7400 coronary angiograms to find out the pattern and incidence of coronary anomalies of origin and distribution. We excluded patients with congenital heart diseases, coronary artery fistulae and patients with separate origin of the conus artery. and found 34 cases (0.46%) (22 males), mean age 50.7 +/- 12 years with coronary anomalies. Six cases underwent angiography prior to valve replacement and the rest were part of the evaluation for atherosclerotic coronary artery disease. The most common anomaly was separate origins of the left anterior descending coronary artery and left circumflex coronary artery [n=12 (35.3%)]. The next most common anomalies were origins of the right coronary artery from the left coronary sinus [n=7 (20.6%)] and left circumflex artery from the right sinus [n=6 (20%)]. A single coronary artery was seen in 3 cases (8.8%) which included one case of postmyocardial infarction ventricular septal rupture with triple-vessel disease, and another with two small coronary fistulae. One case each of the following coronary anomalies was found: (i) double right coronary artery, (ii) left anterior descending coronary artery from the right coronary sinus, (iii) all three coronary arteries originating separately from the right sinus, and (iv) left main coronary artery from the right sinus. Of these 34 patients, 11 (32.4%) had significant atherosclerotic disease in the anomalous vessel. CONCLUSIONS: The incidence of primary coronary anomaly seems to be less than that in earlier reports, but the pattern of anomalies appears to be similar.     

Anomalous origin of the left circumflex coronary artery from the right coronary artery and the left anterior descending artery from the right coronary sinus

We present the case of a 67-year-old female who was admitted to our institution because of anginal chest pain. Selective coronary angiography revealed separate ostial origins of the left anterior descending (LAD) artery and the right coronary artery (RCA) from the right coronary sinus (RCS). The left circumflex (LCx) coronary artery arose from the proximal RCA. The left anterior descending had an anterior free wall and the LCx had a retroaortic course. To our knowledge, this type of combination of anatomical variation of coronary circulation has not been described in the literature.     

The mystery of the lost and found right coronary artery

Most coronary artery anomalies are discovered only incidentally during coronary angiography. Recognition and identification of these anomalies especially during coronary intervention procedures are of importance because of their occasional association with symptoms due to atherosclerotic coronary disease. Anomalous origin of the right coronary artery (RCA) from the left anterior descending coronary artery (LAD) is one of the most uncommon coronary anomalies. We report an extremely interesting case of anomalous RCA from the LAD presenting as acute inferior ST elevation MI, with ostial total block of the RCA, precluding its visualization during coronary angiography. Interventional Cardiologists need to be aware of such anatomical variations, as occasionally, this can lead to a diagnostic dilemma, as in our case. © 2010 Wiley‐Liss, Inc.     

Anomalous origin of the right coronary artery with multiple coronary bicameral fistulae

Cardiac computed tomography surpasses the limitations of conventional coronary angiography and transthoracic echocardiography in determining the origin, course, and extent of coronary artery anomalies. This case report illustrates a rare combination of congenital coronary artery anomalies consisting of anomalous origin of the right coronary artery arising from the left sinus of Valsalva and multiple coronary bicameral fistulae.     

Left anterior descending artery of anomalous origin; Native lad arises from left internal mammarian artery. A case report and article review

Coronary artery anomalies are encountered in 2.6% of the population. Left anterior descending artery (LAD) stemming from a separate ostium is seen at a rate of 0.48%. In this case, we reported on a left internal mammarian artery (LIMA) giving rise to LAD. Coronary angiography was performed through the right radial artery in 54-year-old female patient. It did not reveal the presence of left main coronary artery in all three aortic sinuses. Pulmonary angiography also did not demonstrate LAD stemming from the pulmonary artery. Then, the LIMA was selectively visualized, and LAD originating from LIMA was observed. The PubMed database contains no reports of LIMA giving rise to LAD. This is the first case report demonstrating LAD originating from LIMA. Accordingly, if LAD cannot be visualized during angiography, an angiographic image of LIMA should be taken before a diagnosis of atresic LAD. For angiographic examination, the right radial route can be used.     

A single coronary artery from the right sinus of valsalva associated with atherosclerosis

Anomalous origin of the main coronary arteries from the aorta is rare. We report a case with a single coronary artery from the right sinus of Valsalva associated with atherosclerosis.The patient was treated with a coronary artery bypass procedure: left internal mammary artery (LIMA) to the left anterior descending artery (LAD), right internal mammary artery (RIMA) to the right coronary artery (RCA).The postoperative course was uneventful.     

Anomalous origin of left anterior descending and circumflex coronary artery from two separate ostia in the right sinus of valsalva with unusual dominant right coronary artery

Anomalous origin of left anterior descending (LAD) and left circumflex (LCX) coronary artery from two separate ostia in the right sinus of Valsalva (RSOV) with unusual dominant right coronary artery is an exceedingly rare congenital coronary anomaly. We report a case of a 69-year old woman who was admitted to the hospital because of atypical chest pain. Both multislice computed tomography and coronary angiography revealed this kind of anomaly. Since the benign anomaly and the absence of definite ischemia, the patient doesn't need any specific therapy for this anomaly and is required regular follow-up.