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Dual Left Anterior Descending Artery Arising From Left Circumflex Artery With an Intramyocardial Coronary Aneurysm
Canadian Journal of Cardiology 29 (2013) 1742.e21e1742.e23 www.onlinecjc.ca
Case Report
Dual Left Anterior Descending Artery Arising From Left Circumflex Artery With an Intramyocardial Coronary Aneurysm Dong Li, MD,a,* Jingjing Guo, BM,b,* Yan Han, MM,a Zhang Zhang, MD,a Xiangdong Yu, MD,c Heng Cai, MD,c Liang Zhang, BM,c Qian Cui, MM,a and Tielian Yu, MDa a
Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China b
c
Department of Neuroradiology, Tianjin Huanhu Hospital, Tianjin, China
Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
ABSTRACT
RESUM E
Dual left anterior descending (LAD) artery is a rare anomaly conventionally classified into 4 types. We present a case of dual LAD artery in which the long LAD artery has arisen from the left circumflex (LCx) artery, a condition not previously included in the 4 defined types. Moreover, the long LAD artery specified here is associated with an intramyocardial coronary aneurysm. To our best knowledge, it is the first time such a coronary artery anomaly has been reported. This case suggests the important role of coronary computed tomography angiography (CTTA) for diagnosis and therapeutic planning for such an anomaly.
rieure (IVA) double est une anomalie L’artère interventriculaire ante e en 4 types. Nous pre sentons rare qui est traditionnellement classifie un cas d’artère IVA double dont l’artère IVA longue provient de l’artère te incluse circonflexe gauche (CxG), une affection qui n’avait pas e rieurement dans les 4 types de jà de finis. De plus, l’artère IVA ante e ici est associe e à un ane vrisme intramyocardique longue mentionne coronarien. Autant que nous sachions, c’est la première fois que cette tait signale e. Ce cas suggère le rôle anomalie de l’artère coronaire e trie (Coro-TDM) important de la coronarographie par tomodensitome rapeutique d’une telle dans le diagnostic et la planification the anomalie.
Case Presentation A 67-year-old woman with atypical chest pain underwent both coronary computed tomography angiography (CCTA) and coronary angiography (CAG). CCTA showed the complex coronary anatomy displayed a dual left anterior descending (LAD) artery. The LAD artery proper gave off the short LAD artery that terminated in the proximal portion of the anterior interventricular groove (AIVG). The left circumflex (LCx) artery gave rise to the long LAD artery in its midsegment. The first portion of the long LAD artery was formed by a large transverse trunk running along the surface of the left ventricle before making a sharp turn to enter the AIVG. At the corner turning down to the AIVG, the long LAD artery was found to be dilated because of a dumbbell-shaped aneurysm. The distal part of the
aneurysm was enclosed by the myocardium (Fig. 1). CAG supported the CCTA findings. The intramyocardial part of the aneurysm expanded to 4.4 4.2 mm during diastole and disappeared during systole. The remaining section of aneurysm also decreased from 4.4 5.2 mm to 4.2 3.5 mm during the cardiac cycle (Fig. 2). The patient was discharged 2 days later after CAG, without further management.
Received for publication March 13, 2013. Accepted April 9, 2013. Corresponding author: Dr Tielian Yu, Department of Radiology, Tianjin Medical University General Hospital, #154 Anshan Road, Heping District, Tianjin 300052, China. Tel.: þ86-22-60362739; fax: þ86-22-60362990. E-mail: [email protected] *These authors contributed equally to this work. See page 1742.e23 for disclosure information.
Discussion Dual LAD artery is a rare congenital anomaly described by Spindola-Franco et al. in 1983.1 It consists of a short LAD artery that ends at the proximal portion of the AIVG and a long LAD artery that enters the distal portion of the AIVG. According to the origin and course of the long LAD artery, a dual LAD artery can be traditionally classified into 4 types. For types I-III, the long LAD artery consists of an early branch of the LAD artery proper that takes different courses depending on type. Type IV is defined by the long LAD artery originating from the right coronary artery. Our patient had 2 LAD arteries in the AIVG and thus met the diagnosis criterion of dual LAD artery. However, the long LAD artery
0828-282X/$ - see front matter Crown Copyright Ó 2013 Published by Elsevier Inc on behalf of the Canadian Cardiovascular Society. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2013.04.012
1742.e22
Canadian Journal of Cardiology Volume 29 2013
Figure 1. Coronary computed tomography (CT) images. (A) Volume rendering image displays the dual left anterior descending (LAD) artery. The short LAD artery terminates in the proximal portion of the anterior interventricular groove (AIVG). The long LAD artery originates from the left circumflex (LCx) artery and takes an anomalous course along the surface of the left ventricle before entering the AIVG. A dumbbell-shaped aneurysm (white arrows, A-D) is located at the turning point where the long LAD artery enters the AIVG. (B) Curved planar reformation image shows the origin and course of the long LAD artery and also the unusual location of the aneurysm. The aneurysm is partly enclosed by myocardium. Multiplanar reformation images in the left ventricle long-axis (C) and short-axis (D) planes reveal the myocardial coverage of the aneurysm. (B) and (D) demonstrate that the intramyocardial coronary aneurysm sits beside the right ventricular outflow tract (RVOT); however, there is no communication between them. Ao, ascending aorta; LA, left atrium.
arose from the left circumflex (LCx) artery instead of from the LAD artery proper or the right coronary artery. Such an anomaly has not been described before and is not included in the 4 types. To our knowledge, there have been only 2 cases reported showing the intramyocardial coronary aneurysm, 1 in the LAD artery2 and the other in the septal branch of the LAD artery.3 The cause of the formation of the intramyocardial coronary aneurysm is not clear and may be either congenital or related to a secondary change of local hemodynamics. Identification of this very rare anomaly has clinical significance. CAG may misinterpret the anomaly as occlusion of the midportion of the LAD artery with collateral vessels from the LCx artery. When such patients require surgical
revascularization, the correct location for anastomosis depends on determining which of the LAD arteriesdlong or shortdis obstructive. In addition, the intramyocardial coronary aneurysm may not be apparent during surgery because it is located below the epicardial surface. CCTA can visualize both coronary artery anomalies4 and intramyocardial course5 in a more sensitive and comprehensive way than can CAG. Therefore, CCTA will provide more useful findings for confirming this anomaly, which will be important for diagnosis and therapy planning. Funding Sources This work was supported by Tianjin Application Basis and Leading Edge Research Program grant 10JCYBJC11000. Dr
Li et al. LAD Arising From LCx With a Coronary Aneurysm
1742.e23
Figure 2. Coronary angiography images. Images of diastole (A) and systole (B) verify the findings of coronary computed tomography angiography (CCTA) and display the changes of the aneurysm (white arrow) in shape and size during the cardiac cycle. LAD, left anterior descending; LCx, left circumflex.
Li was supported by New Century Talent Funding of Tianjin Medical University General Hospital.
Disclosures The authors have no conflicts of interest to disclose.
2. Singh SK, Ihnken KA. Intraoperative fluorescence angiography to identify and confirm repair of intramyocardial left anterior descending coronary artery aneurysm. Ann Thorac Surg 2010;90:e62. 3. Gungor B, Gurkan U, Alper AT, et al. Intramyocardial coronary aneurysm: a distinct clinical entity. Int J Cardiol 2011;153:e39-40.
References
4. Shriki JE, Shinbane JS, Rashid MA, et al. Identifying, characterizing, and classifying congenital anomalies of the coronary arteries. Radiographics 2012;32:453-68.
1. 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;105:445-55.
5. Leschka S, Koepfli P, Husmann L, et al. Myocardial bridging: depiction rate and morphology at CT coronary angiography-comparison with conventional coronary angiography. Radiology 2008;246:754-62.
Case Report
Dual Left Anterior Descending Artery Arising From Left Circumflex Artery With an Intramyocardial Coronary Aneurysm Dong Li, MD,a,* Jingjing Guo, BM,b,* Yan Han, MM,a Zhang Zhang, MD,a Xiangdong Yu, MD,c Heng Cai, MD,c Liang Zhang, BM,c Qian Cui, MM,a and Tielian Yu, MDa a
Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China b
c
Department of Neuroradiology, Tianjin Huanhu Hospital, Tianjin, China
Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
ABSTRACT
RESUM E
Dual left anterior descending (LAD) artery is a rare anomaly conventionally classified into 4 types. We present a case of dual LAD artery in which the long LAD artery has arisen from the left circumflex (LCx) artery, a condition not previously included in the 4 defined types. Moreover, the long LAD artery specified here is associated with an intramyocardial coronary aneurysm. To our best knowledge, it is the first time such a coronary artery anomaly has been reported. This case suggests the important role of coronary computed tomography angiography (CTTA) for diagnosis and therapeutic planning for such an anomaly.
rieure (IVA) double est une anomalie L’artère interventriculaire ante e en 4 types. Nous pre sentons rare qui est traditionnellement classifie un cas d’artère IVA double dont l’artère IVA longue provient de l’artère te incluse circonflexe gauche (CxG), une affection qui n’avait pas e rieurement dans les 4 types de jà de finis. De plus, l’artère IVA ante e ici est associe e à un ane vrisme intramyocardique longue mentionne coronarien. Autant que nous sachions, c’est la première fois que cette tait signale e. Ce cas suggère le rôle anomalie de l’artère coronaire e trie (Coro-TDM) important de la coronarographie par tomodensitome rapeutique d’une telle dans le diagnostic et la planification the anomalie.
Case Presentation A 67-year-old woman with atypical chest pain underwent both coronary computed tomography angiography (CCTA) and coronary angiography (CAG). CCTA showed the complex coronary anatomy displayed a dual left anterior descending (LAD) artery. The LAD artery proper gave off the short LAD artery that terminated in the proximal portion of the anterior interventricular groove (AIVG). The left circumflex (LCx) artery gave rise to the long LAD artery in its midsegment. The first portion of the long LAD artery was formed by a large transverse trunk running along the surface of the left ventricle before making a sharp turn to enter the AIVG. At the corner turning down to the AIVG, the long LAD artery was found to be dilated because of a dumbbell-shaped aneurysm. The distal part of the
aneurysm was enclosed by the myocardium (Fig. 1). CAG supported the CCTA findings. The intramyocardial part of the aneurysm expanded to 4.4 4.2 mm during diastole and disappeared during systole. The remaining section of aneurysm also decreased from 4.4 5.2 mm to 4.2 3.5 mm during the cardiac cycle (Fig. 2). The patient was discharged 2 days later after CAG, without further management.
Received for publication March 13, 2013. Accepted April 9, 2013. Corresponding author: Dr Tielian Yu, Department of Radiology, Tianjin Medical University General Hospital, #154 Anshan Road, Heping District, Tianjin 300052, China. Tel.: þ86-22-60362739; fax: þ86-22-60362990. E-mail: [email protected] *These authors contributed equally to this work. See page 1742.e23 for disclosure information.
Discussion Dual LAD artery is a rare congenital anomaly described by Spindola-Franco et al. in 1983.1 It consists of a short LAD artery that ends at the proximal portion of the AIVG and a long LAD artery that enters the distal portion of the AIVG. According to the origin and course of the long LAD artery, a dual LAD artery can be traditionally classified into 4 types. For types I-III, the long LAD artery consists of an early branch of the LAD artery proper that takes different courses depending on type. Type IV is defined by the long LAD artery originating from the right coronary artery. Our patient had 2 LAD arteries in the AIVG and thus met the diagnosis criterion of dual LAD artery. However, the long LAD artery
0828-282X/$ - see front matter Crown Copyright Ó 2013 Published by Elsevier Inc on behalf of the Canadian Cardiovascular Society. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2013.04.012
1742.e22
Canadian Journal of Cardiology Volume 29 2013
Figure 1. Coronary computed tomography (CT) images. (A) Volume rendering image displays the dual left anterior descending (LAD) artery. The short LAD artery terminates in the proximal portion of the anterior interventricular groove (AIVG). The long LAD artery originates from the left circumflex (LCx) artery and takes an anomalous course along the surface of the left ventricle before entering the AIVG. A dumbbell-shaped aneurysm (white arrows, A-D) is located at the turning point where the long LAD artery enters the AIVG. (B) Curved planar reformation image shows the origin and course of the long LAD artery and also the unusual location of the aneurysm. The aneurysm is partly enclosed by myocardium. Multiplanar reformation images in the left ventricle long-axis (C) and short-axis (D) planes reveal the myocardial coverage of the aneurysm. (B) and (D) demonstrate that the intramyocardial coronary aneurysm sits beside the right ventricular outflow tract (RVOT); however, there is no communication between them. Ao, ascending aorta; LA, left atrium.
arose from the left circumflex (LCx) artery instead of from the LAD artery proper or the right coronary artery. Such an anomaly has not been described before and is not included in the 4 types. To our knowledge, there have been only 2 cases reported showing the intramyocardial coronary aneurysm, 1 in the LAD artery2 and the other in the septal branch of the LAD artery.3 The cause of the formation of the intramyocardial coronary aneurysm is not clear and may be either congenital or related to a secondary change of local hemodynamics. Identification of this very rare anomaly has clinical significance. CAG may misinterpret the anomaly as occlusion of the midportion of the LAD artery with collateral vessels from the LCx artery. When such patients require surgical
revascularization, the correct location for anastomosis depends on determining which of the LAD arteriesdlong or shortdis obstructive. In addition, the intramyocardial coronary aneurysm may not be apparent during surgery because it is located below the epicardial surface. CCTA can visualize both coronary artery anomalies4 and intramyocardial course5 in a more sensitive and comprehensive way than can CAG. Therefore, CCTA will provide more useful findings for confirming this anomaly, which will be important for diagnosis and therapy planning. Funding Sources This work was supported by Tianjin Application Basis and Leading Edge Research Program grant 10JCYBJC11000. Dr
Li et al. LAD Arising From LCx With a Coronary Aneurysm
1742.e23
Figure 2. Coronary angiography images. Images of diastole (A) and systole (B) verify the findings of coronary computed tomography angiography (CCTA) and display the changes of the aneurysm (white arrow) in shape and size during the cardiac cycle. LAD, left anterior descending; LCx, left circumflex.
Li was supported by New Century Talent Funding of Tianjin Medical University General Hospital.
Disclosures The authors have no conflicts of interest to disclose.
2. Singh SK, Ihnken KA. Intraoperative fluorescence angiography to identify and confirm repair of intramyocardial left anterior descending coronary artery aneurysm. Ann Thorac Surg 2010;90:e62. 3. Gungor B, Gurkan U, Alper AT, et al. Intramyocardial coronary aneurysm: a distinct clinical entity. Int J Cardiol 2011;153:e39-40.
References
4. Shriki JE, Shinbane JS, Rashid MA, et al. Identifying, characterizing, and classifying congenital anomalies of the coronary arteries. Radiographics 2012;32:453-68.
1. 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;105:445-55.
5. Leschka S, Koepfli P, Husmann L, et al. Myocardial bridging: depiction rate and morphology at CT coronary angiography-comparison with conventional coronary angiography. Radiology 2008;246:754-62.