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Anomalous Twin Circumflex Artery Identified By Invasive Coronary Angiography and Non-Invasive Multidetector CT Angiography in A 75 Year Old Caribbean Male

Authors:
  • Heart Institute of the Caribbean

Abstract

Coronary artery anomalies are clinically important as there have been reports of sudden death, fatal and non-fatal myocardial infarction associated with exercise in persons with certain types of unusual coronary anatomy. Anomalous origin of the circumflex artery is not an uncommon finding; however dual origin of the circumflex artery is a rare anomaly. An extensive search of literature indicates that there have been only two such prior reports, both with nondominant anomalous left circumflex arteries. We describe here the first report of ‘twin’ circumflex arteries with the anomalous dominant circumflex coronary artery arising from the right coronary trunk and a non-dominant circumflex artery from left coronary artery. This was diagnosed by conventional coronary angiography and then confirmed with 64-slice multidetector computed axial tomographic (MDCT) angiography. To the best of our knowledge, this is the first report of twin circumflex coronary artery clearly demonstrated by both invasive and non-invasive techniques. No such confirmation by MDCT angiography has previously been reported in literature.
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... An anomalous circumflex (Cx) coronary artery arising from the right coronary sinus or the right coronary artery (RCA) is one of the most frequent coronary anomalies, seen in 34.4-57.9% of the patients with coronary anomalies [3,4]. Double Cx coronary arteries, with one originating from the left system and the other from the right system, is an exceptionally rare coronary anomaly that has been reported only a few times in the literature worldwide [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. We present a case of double Cx arteries in a middle-aged male with acute myocardial infarction (MI), and its successful management using percutaneous coronary intervention (PCI) of the diseased right Cx artery (RCX). ...
... Although the anomalous origin of LCX has been described to be one of the most common congenital anomalies in many large angiographic series [3][4], the occurrence of double or twin Cx coronary arteries has been reported very rarely in the literature [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. In most of the reported cases of double Cx arteries, one Cx artery (LCX) had its origin from the left main artery while the other (RCX) had its origin from the right coronary sinus or the RCA [5][6][7][8][9][10][11][12][13][14][15][16][17][18]. ...
... Although the anomalous origin of LCX has been described to be one of the most common congenital anomalies in many large angiographic series [3][4], the occurrence of double or twin Cx coronary arteries has been reported very rarely in the literature [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. In most of the reported cases of double Cx arteries, one Cx artery (LCX) had its origin from the left main artery while the other (RCX) had its origin from the right coronary sinus or the RCA [5][6][7][8][9][10][11][12][13][14][15][16][17][18]. A similar finding was seen in our case with the LCX arising from the left main and the RCX arising from the ostio-proximal part of the RCA. ...
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The anomalous origin of the left circumflex (Cx) artery (LCX) from the right coronary sinus or the right coronary artery (RCA) has been reported as one of the most common congenital coronary anomalies. However, the occurrence of double or twin Cx coronary arteries has been sparsely reported in the literature. We describe a rare case of a middle-aged male with acute myocardial infarction (MI) who had double Cx coronary arteries, one arising from the RCA and the other from the left main coronary artery. He underwent successful angioplasty with the stenting of the culprit right Cx artery (RCX).
... 1,2 One of the most common coronary anomalies is a circumflex (Cx) coronary artery anomalously originating from the right sinus of Valsalva; however double Cx arteries originating from the left and right coronary system is a type of anomaly rarely reported in the literature. [3][4][5][6][7][8] Herein, we report twin Cx coronary arteries originating from the left main coronary artery (LMCA) and right coronary artery (RCA). We performed percutaneous coronary intervention (PCI) for anomalous artery stenosis via transradial access. ...
... There are only a few cases of twin Cx arteries originating from both the left and right coronary system that have been reported in the literature. [3][4][5][6][7][8] Cicek et al. reported significant stenoses at both of the twin Cx arteries which led to heart failure, 3 and Karabay et al. reported the kind of anomaly associated with acute myocardial infarction. 4 In the research of Attar et al., they documented a case of twin Cx arteries who presented with coronary artery disease and underwent bypass surgery. ...
Article
Unlabelled: Coronary artery anomalies are rare in population and most of them are found incidentally during coronary angiography. Percutaneous treatment of critical lesions on anomalous arteries may lead to difficulties due to their abnormal origin or course. Herein, we report a 65-year-old male patient presented with recent onset chest pain. Electrocardiogram and transthoracic echocardiography were in normal range. Treadmill exercise test revealed ST segment depression in lead V4-V6. Angiography revealed an unusual coronary anomaly: twin circumflex arteries originating from left main coronary artery and same orifice of right coronary artery, respectively. There was a significant stenosis on the right sided circumflex artery, which was treated percutaneously via transradial access. Key words: Coronary artery anomalies; Percutaneous coronary intervention; Transradial access; Twin circumflex arteries.
... The heart ventricles are relaxed and the heart fills with blood in diastole phase [37]. The ventricles contract and pump blood to the arteries in systole phase [38]. When the heart fills with blood and the blood is pumped out of the heart one cardiac cycle gets complete. ...
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Anomalous origin of circumflex coronary is not an uncommon finding. However, dual origin of circumflex artery is a rare anomaly. An extensive literature search indicates that there have been only three such prior reports. We report the first such case from the Indian subcontinent. This was diagnosed by conventional angiography and CT angiography.
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We describe a patient with two separate vessels having different origins supplying the circumflex coronary artery distribution. This represents a previously undescribed coronary artery anomaly.
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Limited information is available about clinical presentation, degree of atherosclerosis and effect on overall survival in a large series of patients with coronary artery anomalies. From the National Heart, Lung, and Blood Institute Multicenter Coronary Artery Surgery Study (CASS), detailed coding of coronary angiograms was available in 24,959 patients. Of these patients, 73 (0.3%) had major coronary artery anomalies: 70 had one coronary anomaly and 3 had two coronary anomalies. The most common anomaly involved the circumflex coronary artery (60%). In 69% of these, the circumflex artery arose from a separate ostium in the right coronary sinus, and in 31% it originated as a branch of the right coronary artery. The most common anomalous course was anterior or posterior to the great vessels but not between the great vessels. The major exception to this finding was an anomalous right coronary artery; 7 of 15 such arteries coursed between the great vessels. Anomalous circumflex coronary arteries had a significantly greater degree of stenosis than that in nonanomalous arteries in age- and gender-matched control patients (p = 0.02). Despite this difference, at 7 years there was no significant difference in survival by location or degree of stenosis in the anomalous artery.
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Anomalous origin of the circumflex coronary artery from the proximal right coronary artery or right sinus of Valsalva was recognized in 20 of 2996 patients undergoing selective coronary arteriography (0.67%). The relative frequency of this anomaly demands a high level of anticipation during the performance of selective coronary arteriography to assure that an adequate study has been obtained. Failure to recognize and properly demonstrate the anomaly can be hazardous to patient management. Two angiographic signs have proved reliable in recognizing the anomalous artery before its selective demonstration. These signs are a profile view of the artery behind the aortic root during left ventriculography (the "aortic root sign") and recognition of absent arterial inflow to a significant area of the posterior lateral left ventricle during selective injections of the main left coronary artery (the "sign of non-perfused myocardium"). These angiographic signs are described and the clinical implications of proper demonstration of the anomalous circumflex coronary artery are discussed.
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Twenty-one patients with anomalous coronary artery origin from the aorta are discussed, and the cases reported in the literature are reviewed. The left anterior descending (LAD) and left circumflex (Cx) arteries arose aberrantly from the right sinus of Valsalva of the aorta (RSV) in six patients. In four of these patients the connecting branch from the anomalous origin passed anterior to the aorta and the right ventricular in-fundibulum (RVinf), and in two patients, this branch passed between the aorta and RVinf. In 11 patients only the Cx was aberrant, and arose either from the RSV directly or from the right coronary artery (RCA), and passed posterior to the aorta and RVinf. In four patients the RCA arose aberrantly — in three from the left sinus of Valsalva of the aorta passing anteriorly, and in one from the left Cx passing posteriorly. Aberrant coronary artery origin from the aorta had clinical consequences only when the branch connecting the LAD and Cx to the RSV passed between the aorta and RVinf. Both our findings and those reported in the literature associate this variant with exertional sudden death in young persons. Anomalous coronary patterns can be delineated readily by selective coronary cineangiography, and as illustrated, the right anterior oblique projection can readily distinguish those prone to sudden death from the clinically insignificant variants. The former can be corrected with coronary artery bypass surgery.