We here present the case of a rarely seen anomalous origin and retropulmonary course of the left circumflex artery from the proximal right coronary artery. The patient suffered from coronary ischemia due to stenotic lesions both in the aberrant circumflex coronary artery and in the first and second diagonal branches. Coronary bypass operation was performed

Bitschnau, S.

Kayhan, N.

Parker, J. A. T. C.

Peivandi, A. A.

Vahl, C. F.

English

PubMed

J. A. T. C. Parker

A. A. Peivandi

S. Bitschnau

N. Kayhan

C. F. Vahl

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International Journal of Vascular Medicine

Anomalous Origin and Retropulmonary Course of an Atherosclerotic Stenosed Left Circumflex Coronary Artery

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Hindawi Publishing Corporation
International Journal of Vascular Medicine
Volume 2010, Article ID 490858, 3 pages
doi:10.1155/2010/490858
Case Report
Anomalous Origin and Retropulmonary Course of an
Atherosclerotic Stenosed Left Circumflex Coronary Artery
J. A. T. C. Parker,1 A. A. Peivandi,1 S. Bitschnau,2 N. Kayhan,1 and C. F. Vahl1
1Department of Cardiothoracic and Vascular Surgery, Hospital of the Johannes Gutenberg-University,
Langenbeckstraße 1, 55131 Mainz, Germany
2Department of Radiology, Hospital of the Johannes Gutenberg-University, 55131 Mainz, Germany
Correspondence should be addressed to A. A. Peivandi, peivandi@uni-mainz.de
Received 31 January 2010; Accepted 1 May 2010
Academic Editor: Erich Minar
Copyright © 2010 J. A. T. C. Parker et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
We here present the case of a rarely seen anomalous origin and retropulmonary course of the left circumflex artery from the
proximal right coronary artery. The patient suﬀered from coronary ischemia due to stenotic lesions both in the aberrant circumflex
coronary artery and in the first and second diagonal branches. Coronary bypass operation was performed.
1. Case Description
A 66-year-old man with a history of sick-sinus-syndrome,
mild arterial hypertension, hyperlipidemia, and carotid
atheromatosis was admitted to our hospital with angina
pectoris and dyspnea, occurring during exercise (NYHA III)
since five months. Physical examination was unremarkable.
The ECG showed sinus bradycardia without ST changes.
Transthoracic echocardiography showed normal left ven-
tricular systolic and diastolic function with sclerosis of the
aortic valve, without insuﬃciency or stenosis and a low-
grade mitral valve insuﬃciency. Evidence of myocardial
ischemia was found when the patient developed ST changes
during the treadmill exercise test. Coronary angiography was
performed and revealed an anomalous origin of the left cir-
cumflex artery (LCx) from the right coronary sinus, in close
proximity to the right coronary ostium. In addition, after
following a retroaortic course, the LCx spiralled caudal of
the pulmonary trunk to resurface in the left atrio-ventricular
groove (Figures 1 and 2). The peripheral distribution of the
LCx was normal. It showed a significant (90%) obstructive
lesion during its course. In addition, second (90%) and third
(60%) significant obstructions were detected in the first and
second diagonal branches (diagonal (D) first (1), second (2)).
Both the left anterior descending coronary artery and the
right coronary artery (RCA) showed diﬀuse sclerosis and
normal distribution. Surgical therapy was initiated and we
performed a coronary bypass operation with a sequential
venous bypass to the LCx and D1.
The postoperative course was uneventful and the patient
was discharged 8 days later.
2. Discussion
Coronary artery anomalies can be found in approximately
0.6% to 1.3% of all patients who are evaluated with coronary
arteriography [1–5].
In the case of an anomalous origin of the LCx which is
one of the most common anomalies [2], the incidence was
0.34% to 0.48% in large studies by Wilkins and Garg et al. [2,
6]. The coronary origins described in the literature originate
from the right sinus of valsalva or from the right coronary
artery [2, 6–8]. In our case, the origin of the LCx was from the
right sinus of valsalva. Uniquely, it followed a dorsal course
around the aorta.
Dilation of the aortic root and the initial oblique course
of the anomalous LCx from the aorta can lead to compres-
sion of the coronary artery and shear stress forces on the
coronary ostium leading to a narrowed, slitlike configuration
of the ostium. In case the proximal segment of the LCx
courses behind the aorta, it can form an acute angulation
between pulmonary trunk and the left ventricle which can be
2 International Journal of Vascular Medicine
Figure 1: Cardiac catheterization image (LAO) demonstrating the
anomalous coronary system. LCx originates from right sinus of
valsalva. Mind the retro-aortal route of the LCx (arrow depicts both
spiralling course of LCx around the aorta and significant stenosis in
LCx).
Anomalous LCx
RCA
Figure 2: Angio CT showing retro-aortal route of anomalous LCx.
potentially hazardous. Angulation between the pulmonary
trunk and the left ventricle can lead to compression of the
intramural segment of the artery. These mechanisms can lead
to severe myocardial ischemia, infarction, and even sudden
death [2, 9–11].
Discussions therefore rebound about the predilection
of anomalous coronary arteries for stenotic atherosclerotic
lesions [1, 2, 6, 8]. However, due to their low incidence, no
study thus far was able to demonstrate convincing evidence
for this. In our patient, stenotic lesions were located in the
middle segment of the aberrant LCx during its retro-aortal
course. This could imply that mechanical compression of the
LCx caused by repeated systolic-diastolic movements during
the cardiac cycle of the aorta may have contributed to the
cause of the stenotic lesion in the aberrant LCx.
In conclusion, we presented a case of a rarely seen
anomalous origin and retro-aortal course of the LCx from
the right sinus of valsalva. Both the anomalous LCx and
D1 showed significant stenotic lesions and we performed a
coronary bypass operation on the symptomatic patient with
a sequential venous bypass to the LCx and D1.
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a r a c a ,A .K i r i l m a z ,G .O n c e l ,D .O n c e l ,H .Y i l m a z

Aborted sudden death in a young football player due to anomalous origin of the left coronary artery: successful surgical correction,”

Anomalous coronary arteries: angiographic ﬁndings in 80 patients,”

Anomalous origin of either the right or left main coronary artery from the aorta without coursing of the anomalistically arising artery between aorta and pulmonary trunk,”

Anomalous right or left coronary artery from the contralateral coronary sinus: “high-risk” abnormalities in the initial coronary artery course and heterogeneous clinical outcomes,”

Coronary artery anomalies in 126,595 patients undergoing coronary arteriography,” Catheterization and Cardiovascular Diagnosis,

Coronary artery anomalies. A review of more than 10,000 patients from the Clayton Cardiovascular Laboratories,”

Major variations in anatomical origin of the coronary arteries: angiographic observations in 4,250 patients without associated congenital heart disease,” Catheterization and Cardiovascular Diagnosis,

N.Garg,S.Tewari,A.Kapoor,D.K.Gupta,andN.Sinha,“Primarycongenitalanomaliesofthecoronaryarteries:acoronary arteriographic study,”

P a g eJ r . ,H .J .E n g e l ,W .B .C a m p b e l l ,a n dC .S . Thomas Jr., “Anomalous origin of the left circumﬂex coronary artery. Recognition, angiographic demonstration and clinical signiﬁcance,”

Sudden death related to an anomalous origin of the right coronary artery,”

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Anomalous Origin and Retropulmonary Course of an Atherosclerotic Stenosed Left Circumflex Coronary Artery

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