Case Report/Structural Heart Disease
Type IV Dual Left Anterior Descending Artery Associated with
Anomalous Origin of the Left Circumflex Coronary Artery from
the Right Coronary Artery: A Case Report
Sedat Turkoglu, MD, Serhat Balcioglu, MD, Murat Ozdemir, MD
Vol. 20, No. 12, December 2008669
ABSTRACT: Dual left anterior descending coronary artery
(LAD) originating from the left main stem and the right coronary ar-
tery (RCA) (Type IV dual LAD) is a very rare coronary artery anomaly.
Association of this anomaly with the anomalous origin of the circum-
flex artery from the RCA is a very rare occurrence. In this report, we
describe a patient presenting with acute lateral wall myocardial infarc-
tion who subsequently was found to have this coronary anomaly.
J INVASIVE CARDIOL 2008;20:669–670
Key words: coronary anomaly, coronary origin, angiography
Adult coronary anomalies are not very common and are usu-
ally casual findings of diagnostic angiographic studies. The in-
cidence of these anomalies has been reported to be between
0.29% and 1.34% of the general population.1–3Coronary artery
anomalies may involve anomalies of origin and course, anom-
alies of intrinsic coronary arterial anatomy, anomalies of coro-
nary termination and anomalous collateral vessels.4
Herein, we report an unusual case of anomalous coronary
artery circulation who presented with acute lateral wall MI and
underwent successful percutaneous coronary intervention.
Case Report. A 55-year-old male was admitted to our hospital
because of chest pain. The physical examination was completely
normal at presentation. The electrocardiogram revealed ST-segment
elevation in leads I and aVL. He was successfully reperfused by in-
travenous thrombolytic therapy after which both ST-segment ele-
vations and chest pain resolved. He underwent a coronary
angiography on the second day following infarction.
Selective left coronary angiography revealed only a short left an-
terior descending artery (LAD), which terminated at the proximal
segment of the anterior interventricular groove after giving rise to
one major septal and three diagonal branches (Figure 1). There
was a critical stenosis at the LAD just proximal to the third diag-
onal and a major septal artery. Selective right coronary angiography
showed a nondominant right coronary artery (RCA) from which
both the circumflex (Cx) and the LAD originated. The LAD
reached the distal segment of the anterior interventricular groove
by making a cranial anterior loop that indicated an anterior free-
wall course.5The Cx reached the left atrioventricular groove by
using a retroaortic course.5After predilatation with a 2.5 x 16 mm
balloon, the lesion on the LAD was successfully stented using a 2.5
x 12 mm bare-metal stent.
Discussion.Anomalous origin of the Cx from the right coro-
nary sinus (RCS) or the proximal RCA is one of the most com-
mon forms of coronary artery anomalies. It has been reported
in 0.17–0.45% of patients undergoing selective coronary an-
giography.1,6,7In contrast, Type IV dual LAD is a very rarely seen
anomaly.8–10In this anomaly there are two LAD arteries: one
originates from the left main coronary artery and lies in the
proximal anterior interventricular sulcus, and the other one takes
origin from the RCA and lies in the distal anterior interventric-
ular sulcus.8In their original study that defined dual LAD types,
Spindola-Franco et al found only 2 patients with this anomaly
among 2140 patients.8Similarly, Rigatelli et al reported only 2
cases among 5100 angiographic examinations.9A recent study
reported only 3 cases with Type IV double LAD anomaly in
70,850 adult patients undergoing coronary angiography.10
In our case, a Type IV dual LAD was observed in association
with a Cx arising from the proximal RCA. This type of a com-
bination of two distinctly defined coronary anomalies has pre-
viously been reported only twice in the English literature.11,12
From the Department of Cardiology, Gazi University School of Medicine,
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted February 4, 2008, provisional acceptance given February
19, 2008, manuscript accepted March 3, 2008.
Address for correspondence: Sedat Turkoglu, MD, Gazi University School of
Medicine, Department of Cardiology, 06500, Besevler, Ankara, Turkey. E-mail:
Figure 1. Left coronary angiogram in the right anterior oblique caudal
view (A) and the left anterior oblique cranial view (B). Positions demon-
strating a short left anterior descending artery (LAD) that terminated after
giving rise to the septal and diagonal branches. The LAD lesion is also seen.
The first of these two cases presented with acute inferior wall my-
ocardial infarction and the infarct-related artery was found to be
the posterior descending artery and the patient was treated med-
ically.11The second case underwent mechanical aortic valve replace-
ment and coronary artery bypass grafting.12Our case presented with
acute lateral wall myocardial infarction and infarct-related ar-
tery was found to be the proximal LAD, which was successfully
stented. To the best of our knowledge, our report represents the
first case in which percutaneous intervention successfully
opened an occluded artery in this type of extraordinarily rare
1. Click RL, Holmes DR Jr, Vlietstra RE, et al. Anomalous coronary arteries: Location,
degree of atherosclerosis and effect on survival — A report from the Coronary Artery
Surgery Study. J Am Coll Cardiol 1989;13:531–537.
2. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing
coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28–40.
3. Kardos A, Babai L, Rudas L, et al. Epidemiology of congenital coronary artery anom-
alies: A coronary arteriography study on a central European population. Cathet Car-
diovasc Diagn 1997;42:270–275.
4. Angelini P, Velasco JA, Flamm S. Coronary anomalies: Incidence, pathophysiology,
and clinical relevance. Circulation 2002;105:2449–2454.
Ishikawa T, Brandt PW. Anomalous origin of the left main coronary artery from the
right anterior aortic sinus: Angiographic definition of anomalous course. Am J Car-
Topaz O, DeMarchena EJ, Perin E, et al. Anomalous coronary arteries: Angiographic
findings in 80 patients. Int J Cardiol 1992;34:129–138.
7. Chaitman BR, Lesperance J, Saltiel J, Bourassa MG. Clinical, angiographic, and he-
modynamic findings in patients with anomalous origin of the coronary arteries. Cir-
8. Spindola-Franco H, Grose R, Solomon N. Dual left anterior descending coronary
artery: Angiographic description of important variants and surgical implications. Am
Heart J 1983;105:445–455.
Rigatelli G, Docali G, Rossi P, et al. Validation of a clinical-significance-based classifi-
cation of coronary artery anomalies. Angiology 2005;56:25–34.
10. Tuncer C, Batyraliev T, Yilmaz R, et al. Origin and distribution anomalies of the left
anterior descending artery in 70,850 adult patients: Multicenter data collection.
Catheter Cardiovasc Interv 2006;68:574–585.
11. Tutar E, Gulec S, Pamir G, et al. A case of type IV dual left anterior descending artery
associated with anomalous origin of the left circumflex artery in the presence of coro-
nary atherosclerosis. J Invasive Cardiol 1999;11:631–634.
12. Bitigen A, Erkol A, Oduncu V, et al. Atherosclerosis in type IV dual left anterior de-
scending artery and anomalous aortic origin of the left circumflex artery in association
with rheumatic valve disease: A case report. Heart Surg Forum 2007;10:E276–E278.
TURKOGLU, et al.
The Journal of Invasive Cardiology
Figure 2. Right coronary angiogram in the LAO (A) and the RAO (B)
positions. The distal left anterior descending artery and the circumflex
artery originated from the proximal right coronary artery.
Figure 3. Post-stenting left coronary angiogram in the postero-anterior
cranial (A) and LAO cranial (B) projections.