Right Anomalous Coronary Artery Origin: The Role of Multislice CT Angiography

Celly A Atmadikoesoemah,Elen Elen,Isyana M Kurniawan,Manoefris Kasim

doi:10.30701/ijc.v35i4.495

Abstract

Introduction: The anomalous origin of the right coronary artery (RCA) from the left coronary sinus coursing between the aorta and the pulmonary trunk is rare, but may cause myocardial ischemia and sudden death. Multislice CT coronaryangiography offers the possibility to visualize anomalous coronary artery origin non-invasively in details.Case Illustration: A 54-year-old man with a history of arterial hypertension, and hypercholesterolemia began to present with typical chest pain. After some non-invasive examination, he had coronary angiographythat revealed 70% stenosis at mid intermediate artery, normalLMCA, LAD and LCX. Ostium of RCA was found near the left valsava sinus afterrepeated cannulation attempts, no stenosis was found at RCA. After successful revascularization at intermediate artery, patient still had typical chest pain with positive ischemic response in treadmill test. Multislice CT coronary angiography was performedto evaluate the etiology of chest pain. The scan showed patent stent at intermediate artery and anomalous RCA origin from the left coronary sinus withacute angle take-off, luminal narrowing of the osteal-proximal part, as well as luminal compression between the ascending aorta and the pulmonary trunk (an interarterial course) while RCA appeared as dominant vessel. These features were considered as malignant coronary anomaly that could lead to the recommendation of surgical correction.Discussion: Accurate recognition and documentation of coronary artery anomalies are essential to determine the significance of such findings and to avoid furtherclinical complications. Multislice CT coronary angiography is a non-invasive imaging modality that can easily and precisely depict the origin and course of coronary artery anomalies as well as its relationship with adjacent structures.

Highlights

The anomalous origin of the right coronary artery (RCA) from the left coronary sinus coursing between the aorta and the pulmonary trunk is rare, but may cause myocardial ischemia and sudden death
The incidence of the anomalous origin of the RCA from the left coronary sinus (LCS) is 0.019% to 0.49% on coronary angiography.3As Eckart et al report suggests, evidence from autopsy series indicates that anomalous origin of the RCA from the LCS is associated with sudden cardiac death in 25% of cases.[4]
An interarterial course is associated with risk of myocardial ischemia (“malignant anomaly”) because it generally occurs with: a small, slit-like orifice, acute angle takeoff, potential of compression between the great vessels during exercise, due to expansion of the aortic root and pulmonary artery trunk root, and the artery with the anomalous course can be the dominant artery.[6]

Summary

Introduction

The anomalous origin of the right coronary artery (RCA) from the left coronary sinus (LCS) coursing between the aorta and the pulmonary trunk is rare, but may cause myocardial ischemia and sudden death.1Multislice CT coronary angiography offers. He had coronary angiography that revealed 70% stenosis at mid intermediate artery, normal LMCA, LAD and LCX. After successful revascularization at intermediate artery, patient still had typical chest pain with positive ischemic response in treadmill test. Multislice CT coronary angiography was performed to evaluate the etiology of chest pain. The scan showed patent stent at intermediate artery and anomalous RCA origin from the left coronary sinus with acute angle takeoff, luminal narrowing of the osteal-proximal part, as well as luminal compression between the ascending aorta and the pulmonary trunk (an interarterial course) while RCA appeared as dominant vessel. Measurement of diameters for proximal and mid segments of the RCA were 2,1 mm and 3,9 mm, respectively. (Figure 1)

Discussion