Author + information
- Received June 23, 2015
- Accepted July 2, 2015
- Published online November 1, 2015.
- Mohammad Waleed, MBBS, MPH and
- Konstantinos Aznaouridis, MD, PhD∗ ( )()
- Cardiology Department, Castle Hill Hospital, Hull and East Yorkshire NHS Trust, Cottingham, United Kingdom
- ↵∗Reprint requests and correspondence:
Dr. Konstantinos Aznaouridis, Castle Hill Hospital, Hull and East Yorkshire NHS Trust, Castle Road, Cottingham, East Riding of Yorkshire, HU16 5JQ, United Kingdom.
A 47-year-old man was admitted with anterolateral ST-segment elevation myocardial infarction (Figure 1) and underwent emergency coronary angiography through the right radial artery. Attempts to cannulate the nonculprit right coronary artery (RCA) were unsuccessful, and subsequent contrast injection into the right sinus of Valsalva showed that the RCA did not arise from its usual position. Left coronary angiography showed a proximally occluded left anterior descending artery (LAD) and a circumflex artery supplying a high obtuse marginal branch with severe ostial stenosis and a posterior descending branch (Figure 2, Online Video 1). Primary percutaneous coronary intervention to the LAD was performed with standard techniques. After the flow to the LAD was restored, there was an aberrant RCA originating from the mid-LAD, just distal to the origins of the first septal perforator and first diagonal branch (Figure 2, Online Video 2). This ectopic RCA was a small artery with severe diffuse stenosis at the midsegment and provided a small posterior descending artery (codominant circulation) (Figure 2, Online Video 3).
Coronary anomalies are usually found incidentally during coronary angiography, as the majority of these anomalies are benign and the patients remain asymptomatic (1). We present a very rare coronary anomaly of an RCA originating from the midsegment of the LAD. Only very few similar cases have been reported in the published data so far (2,3). A recent study shows that the prevalence of an anomalous RCA arising from LAD has been 0.018% in patients undergoing coronary angiography, which is only the 6% of all anomalies of coronary artery origin and course (3). In this anomaly, the aberrant RCA usually has a course in front of the pulmonary artery and is associated with good prognosis (4).
To our knowledge, this is the first reported case of acute occlusion of an aberrant RCA arising from LAD due to acute thrombosis of proximal LAD. However, our patient had codominant circulation with the anomalous RCA providing a very small posterior descending branch, and therefore he had no evidence of acute inferior wall ischemia (no inferior ST-segment elevations, no inferior wall motion abnormality with quick bedside echocardiography pre-procedure, and no hemodynamic instability).
Interventional cardiologists must be aware of this very rare coronary anomaly. In a setting of emergency catheterization for ST-segment elevation myocardial infarction, revascularization of the culprit artery should be performed promptly if the nonculprit artery cannot be readily cannulated first. In rare cases, the “nonculprit” coronary artery may have an anomalous origin from the culprit artery.
For supplemental videos and their legends, please see the online version of this article.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 23, 2015.
- Accepted July 2, 2015.
- American College of Cardiology Foundation