CORONARY ARTERY CORONARY ARTERY

ANOMALIESANOMALIES

NEW YORK UNIVERSITY

JILL E. JACOBS, M.D., F.A.C.R.JILL E. JACOBS, M.D., F.A.C.R.Professor of RadiologyDepartment Of RadiologyNYU Langone Medical Center

MPR

CURVED MPR

MIP

CORONARY ARTERY VARIANTS & ANOMALIES

MPAAo

Conus branchof RCA

Fistula to MPA

LAD fistula

Distal LAD

Aorta to fistulaconnections

VOLUME RENDERING

AUTOMATICSEGMENTATION

CT HAS BECOME THE GOLD CT HAS BECOME THE GOLD STANDARD!!STANDARD!!

CORONARY ANOMALIES

•• Found incidentally in 0.3Found incidentally in 0.3--1%1%

•• 80% “benign”; 20% potentially symptomatic80% “benign”; 20% potentially symptomatic

CORONARY ANOMALIES

•• Anomalies of originAnomalies of origin

•• Anomalies of courseAnomalies of course

A li f t i tiA li f t i ti•• Anomalies of terminationAnomalies of termination

•• Anomalies of intrinsic anatomyAnomalies of intrinsic anatomy

ANOMALIES OF ORIGIN

•• High take off (~ 6%)High take off (~ 6%)

•• MutipleMutiple ostiaostia (~ 0.4%)(~ 0.4%)

•• Single coronary artery (0.0024Single coronary artery (0.0024--0.044%)0.044%)

O i i f itO i i f it i &i &•• Origin from opposite or Origin from opposite or noncoronarynoncoronary sinus & sinus & anomalous courseanomalous course

•• Origin from pulmonary arteryOrigin from pulmonary artery

ORIGIN OF RCA ABOVE

SINOTUBULAR JUNCTIONRCA LCA

LCARCA

ABSENT LM(Separate Origins of LAD & CX)

LCX

LADLCXLAD

- Occurs in ~ 0.4% pop- Higher incidence of

L dominance and MB

ABSENT LMSEPARATE ORIGINS OF LAD AND CX

LADLAD

CX CX

SINGLE CORONARY ARTERY

•• Among the rarest of CA anomaliesAmong the rarest of CA anomalies

•• Coding System:Coding System:

•• SOV where CA originates: R or LSOV where CA originates: R or L

•• Anatomic course:Anatomic course:-- I: normal anatomic course of arteryI: normal anatomic course of artery

RCA

LCA

-- II: one CA arises from the other normally located II: one CA arises from the other normally located arteryartery

-- III: LAD and LCX arise from III: LAD and LCX arise from

normally positioned RCAnormally positioned RCA

•• Relationship of CA to great vesselsRelationship of CA to great vessels-- A (anterior), P (posterior), B (between), or A (anterior), P (posterior), B (between), or

C (combined)C (combined)

59 YO HYPERTENSIVE MAN

LAD

LAD

ABERRANT RCA

SINGLE CORONARY ARTERY (TYPE L-IIA)

LMCX

ANOMALOUS ORIGIN FROM OPPOSITE OR NONCORONARY SINUS

•• RCA from L sinusRCA from L sinus

•• LCA from R sinusLCA from R sinus

•• LCx or LAD from R sinusLCx or LAD from R sinus

LCA RCA ( b h f ith ) f NCLCA RCA ( b h f ith ) f NC•• LCA or RCA (or branch of either) from NC LCA or RCA (or branch of either) from NC sinussinus

PA AORTA

AORTA

RCA FROM L

PA

RCA FROM L CUSP

RCA FROM L CUSP

TYPES OF ANOMALOUS COURSE

•• INTERARTERIALINTERARTERIAL

•• “malignant configuration”“malignant configuration”

•• Associated with sudden deathAssociated with sudden death

•• RetroaorticRetroaortic

•• PrepulmonicPrepulmonic

•• SeptalSeptal ((subpulmonicsubpulmonic))

Techniques in

Vascular & Interventional

Radiology

2006; 9: 210

INTERARTERIAL

“MALIGNANT CONFIGURATION”“MALIGNANT CONFIGURATION”

RISK OF SUDDEN DEATH

Coronary artery anomalies are the 2nd most common cause of sudden death in competitive athletes after

HCM

44 YO WOMAN WITH

ATYPICAL CHEST PAIN

PULM A

AORTA

RCA FROM L CUSP

RCA

LCA

ANOMALOUSRCA

PULM A

AORTA

ARCA and ALCA

•• RCA arises from the L sinus as a separate vessel or as RCA arises from the L sinus as a separate vessel or as a branch of a single coronary a in 0.03a branch of a single coronary a in 0.03--0.17% of pts on 0.17% of pts on angioangio•• Occurs 4 times more commonly than ALCAOccurs 4 times more commonly than ALCA•• Most common course is Most common course is interarterialinterarterial•• Associated with sudden cardiac death in up to 30% of Associated with sudden cardiac death in up to 30% of

ptsptspp

•• LCA arises from the R sinus as a separate vessel or as LCA arises from the R sinus as a separate vessel or as a branch of a single coronary a in 0.09a branch of a single coronary a in 0.09--0.11% of pts on 0.11% of pts on angioangio•• Most common course is Most common course is septalseptal ((subpulmonicsubpulmonic))•• interarterialinterarterial course has a high risk for sudden death!course has a high risk for sudden death!

-- higher sudden death risk than for ARCAhigher sudden death risk than for ARCA

ANOMALOUS NONDOM RCA

SEPTAL

“SUBPULMONIC”“SUBPULMONIC”

SINGLE CORONARY ARTERY (R-IC)

RCA

RCA

LCA

LCA

Single CA with septal course of LM

PULM outflow

RCA

AORTA

LAD

PULM outflow

AORTA LCA

AORTALCA

LCX

Single CA with septal course of LM

PULM PULM PULM PULM

LCA from RCC with intraseptal course

PULM A

AORTA

RETROAORTIC

47 YO WOMAN WITH

ATYPICAL CHEST PAIN

AORVOT

LMRCC

LCCNCC

RCA

AO

LA LA

ANOMALOUSLM

AOLA LA

ABERRANT CX FROM RCA

PREPULMONIC

62 yo man with chest pain

ABERRANT LM FROM RCC; PREPULMONIC COURSE ABERRANT LM FROM RCC; PREPULMONIC COURSE

LARCCLCC

NCC

RA

RCA

LCXLADRCA FROM NC

CUSP

RCC LCC

NCCLA

RA

ANOMALOUS LT CORONARY A FROM THE PA

PulmonaryArtery

PulmonaryArteryAorta

RCA

LAD

LADCollateralArteries

•• AKA BlandAKA Bland--WhiteWhite--Garland syndromeGarland syndrome

•• Rare, 1:300,000 live birthsRare, 1:300,000 live births

•• 0.240.24--0.46% congenital cardiac disease0.46% congenital cardiac disease

•• females > malesfemales > males

•• Most become symptomatic in infancy & early childhoodMost become symptomatic in infancy & early childhood

•• ~ 90% of untreated infants die in 1~ 90% of untreated infants die in 1stst yr of lifeyr of life

ANOMALOUS LCA FROM THE PA

•• ~ 90% of untreated infants die in 1~ 90% of untreated infants die in 1stst yr of lifeyr of life

•• late presentation likely due to collaterals between the late presentation likely due to collaterals between the RCA and LCARCA and LCA

•• “coronary steal” into the PA “coronary steal” into the PA

•• Retrograde flow in the left coronary circuit to the PARetrograde flow in the left coronary circuit to the PA

•• AoAo RCA Collaterals LCA Pulmonary circuitRCA Collaterals LCA Pulmonary circuit

•• Chronic ischemia Chronic ischemia cardiomyopathycardiomyopathy & CHF& CHF

•• TxTx in adult: ligation of LCA from PA & CABGin adult: ligation of LCA from PA & CABG

Left Main

RCA

PulmonaryArtery

LAD

ANOMALOUS RT CORONARY A FROM THE PA

AortaPulmonary

Artery

RCA

MPA

RPA

Ao

RCA

RCA

MPA

LCA

ARCAPA

RPA

LPA RV LV

ANOMALIES OF COURSE

•• Myocardial bridgingMyocardial bridging

•• Arterial duplicationArterial duplication

MYOCARDIAL BRIDGE DUPLICATED LAD

Kim, S. Y. et al. Radiographics 2006;26:317-333

ANOMALIES OF TERMINATION

•• Coronary artery fistulaCoronary artery fistula

•• Coronary arcadeCoronary arcade

•• Extracardiac terminationExtracardiac termination

LAD TO RPA FISTULA

CORONARY ARTERY FISTULA

•• Communication b/t coronary artery and either Communication b/t coronary artery and either a cardiac chamber (coronarya cardiac chamber (coronary--cameral fistula), cameral fistula), the PA, or a venous structure (the PA, or a venous structure (ieie CS or SVC)CS or SVC)

•• Seen in ~ 0.15% of pts at Seen in ~ 0.15% of pts at cathcath

•• Most involve the RCAMost involve the RCA•• Most involve the RCAMost involve the RCA

•• Feeding artery typically dilated and tortuous Feeding artery typically dilated and tortuous

•• draining into a lower pressure systemdraining into a lower pressure system

•• May cause myocardial ischemia due to “steal May cause myocardial ischemia due to “steal phenomenon”phenomenon”

CORONARY-CAMERAL FISTULARCA TO LEFT ATRIUM FISTULA VIA SA NODAL BRANCH

RCA

SA NODALBRANCH

ANEURYSMAL SEGMENT

CX TO CORONARY SINUS FISTULA

ANOMALIES OF INTRINSIC ANATOMY

•• Congenital Congenital stenosisstenosis or or atresiaatresia

•• Aneurysms and Aneurysms and ectasiaectasia

•• diameter >1.5X the normal diameter >1.5X the normal adjadj segmentsegment

t it i i l 50% l l thi l 50% l l th•• ectasiaectasia involves >50% vessel lengthinvolves >50% vessel length

•• most common world wide cause is most common world wide cause is Kawasaki’s disease (CAD in the USA)Kawasaki’s disease (CAD in the USA)

12 yo with Kawasaki 19 YO WOMAN WITH BEHÇET DISEASE

19 YO WOMAN WITH BEHÇET DISEASE