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Double left anterior descending artery arising from the left and right coronary arteries: Depiction at multidetector-row computed tomography
International Journal of Cardiology 132 (2009) e54 – e56 www.elsevier.com/locate/ijcard
Letter to the Editor
Double left anterior descending artery arising from the left and right coronary arteries: Depiction at multidetector-row computed tomography Satoshi Kunimoto a , Yuichi Sato a,⁎, Taeko Kunimasa a , Yuji Kasamaki a , Tadateru Takayama a , Naoya Matsumoto a , Shu Kasama b , Shunicni Yoda a , Satoshi Saito a , Atsushi Hirayama a a
Department of Cardiology, Nihon University School of Medicine, 30-1 Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan b Department Cardiovascular Medicine, Gunma University School of Medicine, Japan Received 23 July 2007; accepted 10 August 2007 Available online 19 November 2007
Abstract Double left anterior descending artery arising from the left and right coronary arteries is an extremely rare congenital coronary anomaly, although it has no clinical significance unless atherosclerotic coronary artery disease superimposes. We describe, for the first time, multidetector-row computed tomographic findings of double left anterior descending artery. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: MDCT; Double left anterior descending artery; Coronary artery anomaly
1. Case report A 65-year-old woman underwent coronary multidetectorrow computed tomography (MDCT) angiography for the assessment of coronary artery disease prior to the surgical repair for atrial septal defect which had been diagnosed 6 months earlier. MDCT was performed using an Aquillion 16 (16-detector-row, Toshiba Medical, Tokyo) which provided a spatial resolution of 0.5 mm and a temporal resolution of 200 ms. The scan parameters and protocol have been reported previously [1]. Volume rendering image from the cranial right anterior oblique view showed that an anomalous left anterior descending artery (LAD) arose from the proximal portion of the right coronary artery, which coursed downwardly along the interventricular sulcus (Fig. 1A). Volume rendering image from the anterior view showed anther LAD arising from the left main coronary artery, which distributed to the anterior wall of the left ventricle and terminated before reaching the left ventricular apex (Fig. 1B). Conventional selective coronary angiogra⁎ Corresponding author. Tel.: +81 3 3293 1711; fax: +81 3 3295 1859. E-mail address: [email protected] (Y. Sato). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.08.019
phy was performed. Right coronary angiogram disclosed an anomalous LAD arising from the proximal right coronary artery and giving off septal branches (Fig. 2A). Left coronary angiogram showed the LAD and the left circumflex artery. The LAD was short and the mid and distal portions were avascular (Fig. 2B). There were no significant coronary stenoses or occlusions. These MDCT and coronary angiographic findings were considered to be consistent with double LAD, with one vessel arising from the right coronary artery and the second one arising from the left main coronary artery. 2. Discussion Double LAD originating from both the right coronary and the left main coronary artery is an extremely rare congenital coronary artery anomaly. So far this anomaly has been reported in only 8 cases [2–7]. Spindola-Franco et al. have reported that double LAD can be classified into four types according to the origin and anatomical course from the left and right coronary arteries [2]. Of these, types I–III have a similar pattern; all of them arise separately from the proximal part of the left anterior descending artery and/or are divided
S. Kunimoto et al. / International Journal of Cardiology 132 (2009) e54–e56
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Fig. 1. A: Volume rendering image from the cranial right anterior oblique view showing anomalous left anterior descending artery (LAD) arising from the right coronary artery and coursing along the interventricular sulcus (arrow). B: Volume rendering image from the anterior view showing the LAD (arrow) arising from the left main coronary artery to supply the left anterior wall.
Fig. 2. A: Right coronary angiogram in right anterior oblique projection showing anomalous left anterior descending artery (LAD) arising from the proximal right coronary artery (RCA). B: Left coronary angiogram in right anterior oblique projection showing a short LAD that terminates after giving off the second diagonal branch. LCx = left circumflex artery.
into two left coronary arteries. Type IV is defined as the presence of two separate LADs, a short LAD arising from the left main coronary artery and a long LAD arising from the right coronary artery or right sinus of Valsalva. According to this classification, the MDCT and angiographic findings of our case are consistent with type IV. Although double LAD is thought to have benign outcome, recognition of this anomaly is important when atherosclerotic coronary artery disease superimposes [2,6]. For example, it is difficult to differentiate total occlusion of the mid or distal portion of the LAD from this anomaly. Conventional coronary angiography still remains the gold standard for the diagnosis of coronary artery disease. However, identification of coronary artery anomalies is frequently difficult with conventional coronary angiography because of the lack of 3-dimensional information which relates the origins and courses of the coronary arteries to specific locations of the heart. This is particularly important when the anomalous
vessel courses between the aorta and the right ventricular outflow tract because this condition may provoke myocardial ischemia and sudden death [1]. MDCT allows 3-D comprehension of the coronary artery system and it is extremely useful to identify congenital coronary artery anomalies. To the best of our knowledge, this is the first report describing MDCT findings in a patient with double LAD. References [1] Sato Y, Matsumoto N, Iida J, et al. Discrete subaortic stenosis after the correction of atrioventricular septal defect in an adult. Int J Cardiol 2005;109:291–2. [2] 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. [3] Voudris V, Salachas A, Saounotsou M, et al. Double left anterior descending artery originating from the left and right coronary artery: a rare coronary artery anomaly. Catheter Cardiovasc Diagn 1993;30:45–7.
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S. Kunimoto et al. / International Journal of Cardiology 132 (2009) e54–e56
[4] Rigatelli G, Gemelli M, Gianfranco F, Rigatelli G. Images in cardiovascular medicine. Double is better: type IV dual left anterior descending coronary artery and superimposed atherosclerosis. Ital Heart J 2001;2:68–9. [5] Turhan H, Atak R, Erbay AR, Senen K, Yetkin E. Double left anterior descending coronary artery arising from the left and right coronary arteries: a rare congenital coronary artery anomaly. Heart Vessels 2004;19:196–8.
[6] Kosar F. An unusual case of double anterior descending artery originating from the left and right coronary arteries. Heart Vessels 2006;21:385–7. [7] Tuncer C, Batyraliev T, Yilmaz R, Gokce M, Eryonucu B, Koroglu S. Origin and distribution anomalies of the left anterior descending artery in 70,850 patients: multicenter data collection. Catheter Cardiovasc Interv 2006;68:574–85.
Letter to the Editor
Double left anterior descending artery arising from the left and right coronary arteries: Depiction at multidetector-row computed tomography Satoshi Kunimoto a , Yuichi Sato a,⁎, Taeko Kunimasa a , Yuji Kasamaki a , Tadateru Takayama a , Naoya Matsumoto a , Shu Kasama b , Shunicni Yoda a , Satoshi Saito a , Atsushi Hirayama a a
Department of Cardiology, Nihon University School of Medicine, 30-1 Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan b Department Cardiovascular Medicine, Gunma University School of Medicine, Japan Received 23 July 2007; accepted 10 August 2007 Available online 19 November 2007
Abstract Double left anterior descending artery arising from the left and right coronary arteries is an extremely rare congenital coronary anomaly, although it has no clinical significance unless atherosclerotic coronary artery disease superimposes. We describe, for the first time, multidetector-row computed tomographic findings of double left anterior descending artery. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: MDCT; Double left anterior descending artery; Coronary artery anomaly
1. Case report A 65-year-old woman underwent coronary multidetectorrow computed tomography (MDCT) angiography for the assessment of coronary artery disease prior to the surgical repair for atrial septal defect which had been diagnosed 6 months earlier. MDCT was performed using an Aquillion 16 (16-detector-row, Toshiba Medical, Tokyo) which provided a spatial resolution of 0.5 mm and a temporal resolution of 200 ms. The scan parameters and protocol have been reported previously [1]. Volume rendering image from the cranial right anterior oblique view showed that an anomalous left anterior descending artery (LAD) arose from the proximal portion of the right coronary artery, which coursed downwardly along the interventricular sulcus (Fig. 1A). Volume rendering image from the anterior view showed anther LAD arising from the left main coronary artery, which distributed to the anterior wall of the left ventricle and terminated before reaching the left ventricular apex (Fig. 1B). Conventional selective coronary angiogra⁎ Corresponding author. Tel.: +81 3 3293 1711; fax: +81 3 3295 1859. E-mail address: [email protected] (Y. Sato). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.08.019
phy was performed. Right coronary angiogram disclosed an anomalous LAD arising from the proximal right coronary artery and giving off septal branches (Fig. 2A). Left coronary angiogram showed the LAD and the left circumflex artery. The LAD was short and the mid and distal portions were avascular (Fig. 2B). There were no significant coronary stenoses or occlusions. These MDCT and coronary angiographic findings were considered to be consistent with double LAD, with one vessel arising from the right coronary artery and the second one arising from the left main coronary artery. 2. Discussion Double LAD originating from both the right coronary and the left main coronary artery is an extremely rare congenital coronary artery anomaly. So far this anomaly has been reported in only 8 cases [2–7]. Spindola-Franco et al. have reported that double LAD can be classified into four types according to the origin and anatomical course from the left and right coronary arteries [2]. Of these, types I–III have a similar pattern; all of them arise separately from the proximal part of the left anterior descending artery and/or are divided
S. Kunimoto et al. / International Journal of Cardiology 132 (2009) e54–e56
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Fig. 1. A: Volume rendering image from the cranial right anterior oblique view showing anomalous left anterior descending artery (LAD) arising from the right coronary artery and coursing along the interventricular sulcus (arrow). B: Volume rendering image from the anterior view showing the LAD (arrow) arising from the left main coronary artery to supply the left anterior wall.
Fig. 2. A: Right coronary angiogram in right anterior oblique projection showing anomalous left anterior descending artery (LAD) arising from the proximal right coronary artery (RCA). B: Left coronary angiogram in right anterior oblique projection showing a short LAD that terminates after giving off the second diagonal branch. LCx = left circumflex artery.
into two left coronary arteries. Type IV is defined as the presence of two separate LADs, a short LAD arising from the left main coronary artery and a long LAD arising from the right coronary artery or right sinus of Valsalva. According to this classification, the MDCT and angiographic findings of our case are consistent with type IV. Although double LAD is thought to have benign outcome, recognition of this anomaly is important when atherosclerotic coronary artery disease superimposes [2,6]. For example, it is difficult to differentiate total occlusion of the mid or distal portion of the LAD from this anomaly. Conventional coronary angiography still remains the gold standard for the diagnosis of coronary artery disease. However, identification of coronary artery anomalies is frequently difficult with conventional coronary angiography because of the lack of 3-dimensional information which relates the origins and courses of the coronary arteries to specific locations of the heart. This is particularly important when the anomalous
vessel courses between the aorta and the right ventricular outflow tract because this condition may provoke myocardial ischemia and sudden death [1]. MDCT allows 3-D comprehension of the coronary artery system and it is extremely useful to identify congenital coronary artery anomalies. To the best of our knowledge, this is the first report describing MDCT findings in a patient with double LAD. References [1] Sato Y, Matsumoto N, Iida J, et al. Discrete subaortic stenosis after the correction of atrioventricular septal defect in an adult. Int J Cardiol 2005;109:291–2. [2] 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. [3] Voudris V, Salachas A, Saounotsou M, et al. Double left anterior descending artery originating from the left and right coronary artery: a rare coronary artery anomaly. Catheter Cardiovasc Diagn 1993;30:45–7.
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S. Kunimoto et al. / International Journal of Cardiology 132 (2009) e54–e56
[4] Rigatelli G, Gemelli M, Gianfranco F, Rigatelli G. Images in cardiovascular medicine. Double is better: type IV dual left anterior descending coronary artery and superimposed atherosclerosis. Ital Heart J 2001;2:68–9. [5] Turhan H, Atak R, Erbay AR, Senen K, Yetkin E. Double left anterior descending coronary artery arising from the left and right coronary arteries: a rare congenital coronary artery anomaly. Heart Vessels 2004;19:196–8.
[6] Kosar F. An unusual case of double anterior descending artery originating from the left and right coronary arteries. Heart Vessels 2006;21:385–7. [7] Tuncer C, Batyraliev T, Yilmaz R, Gokce M, Eryonucu B, Koroglu S. Origin and distribution anomalies of the left anterior descending artery in 70,850 patients: multicenter data collection. Catheter Cardiovasc Interv 2006;68:574–85.