DOI: 10.1148/rg.262055068
Coronary Artery Anomalies: Classification and ECG-gated Multi–Detector Row CT Findings with Angiographic Correlation1
So Yeon Kim, MD,
Joon Beom Seo, MD,
Kyung-Hyun Do, MD,
Jeong-Nam Heo, MD,
Jin Seong Lee, MD,
Jae-Woo Song, MD,
Yeon Hyeon Choe, MD,
Tae Hoon Kim, MD,
Hwan Seok Yong, MD,
Sang Il Choi, MD,
Koun-Sik Song, MD and
Tae-Hwan Lim, MD
1 From the Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1, Pungnap-2 dong, Songpa-ku, Seoul 138-736, Korea (S.Y.K., J.B.S., K.H.D., J.N.H., J.S.L., J.W.S., K.S.S., T.H.L.); the Department of Radiology, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea (Y.H.C.); the Department of Radiology, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (T.H.K.); the Department of Radiology, Korea University College of Medicine, Seoul, Korea (H.S.Y.); and the Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea (S.I.C.). Recipient of a Magna Cum Laude award for an education exhibit at the 2004 RSNA Annual Meeting. Received March 22, 2005; revision requested May 9 and received June 24; accepted June 27. All authors have no financial relationships to disclose.
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Figure 1. Diagrams illustrate the coronary artery anatomy (circle and half-loop model). The circle consists of the RCA and the LCx artery. The half loop is formed by the LAD artery and the PDA.
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Figure 2a. Normal ECG-gated multi–detector row CT anatomy of the RCA and its branches. (a) Oblique volume-rendered (VR) image of the top of the heart shows the RCA (arrow) arising from the right sinus of Valsalva and coursing in the right atrioventricular groove toward the posterior interventricular septum. A = aorta, PA = pulmonary artery. The conus artery and the sinoatrial node artery were too small to be seen in this case. (b) Lateral oblique VR image shows the caudal course of the proximal RCA (arrow), which gives off an acute marginal branch (arrowheads) to the right ventricle. (c) Posterior oblique VR image shows that the distal RCA divides into the PDA (straight arrow) and posterior left ventricular branches (arrowheads). The PDA courses in the posterior interventricular groove, parallel to the middle cardiac vein (curved arrow).
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Figure 2b. Normal ECG-gated multi–detector row CT anatomy of the RCA and its branches. (a) Oblique volume-rendered (VR) image of the top of the heart shows the RCA (arrow) arising from the right sinus of Valsalva and coursing in the right atrioventricular groove toward the posterior interventricular septum. A = aorta, PA = pulmonary artery. The conus artery and the sinoatrial node artery were too small to be seen in this case. (b) Lateral oblique VR image shows the caudal course of the proximal RCA (arrow), which gives off an acute marginal branch (arrowheads) to the right ventricle. (c) Posterior oblique VR image shows that the distal RCA divides into the PDA (straight arrow) and posterior left ventricular branches (arrowheads). The PDA courses in the posterior interventricular groove, parallel to the middle cardiac vein (curved arrow).
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Figure 2c. Normal ECG-gated multi–detector row CT anatomy of the RCA and its branches. (a) Oblique volume-rendered (VR) image of the top of the heart shows the RCA (arrow) arising from the right sinus of Valsalva and coursing in the right atrioventricular groove toward the posterior interventricular septum. A = aorta, PA = pulmonary artery. The conus artery and the sinoatrial node artery were too small to be seen in this case. (b) Lateral oblique VR image shows the caudal course of the proximal RCA (arrow), which gives off an acute marginal branch (arrowheads) to the right ventricle. (c) Posterior oblique VR image shows that the distal RCA divides into the PDA (straight arrow) and posterior left ventricular branches (arrowheads). The PDA courses in the posterior interventricular groove, parallel to the middle cardiac vein (curved arrow).
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Figure 3a. Normal ECG-gated multi–detector row CT anatomy of the LCA and its branches. A = aorta, PA = pulmonary artery. (a) Oblique VR image of the top of the heart shows the LCA (curved arrow) arising from the left sinus of Valsalva and trifurcating into the LAD artery (thin straight arrow), the LCx artery (thick straight arrow), and the ramus intermedius (arrowhead), which takes a course similar to that of the usual first diagonal branch. The LAD artery then gives rise to diagonal branches (short arrows) to the anterior free wall of the left ventricle. (b, c) Anterior (b) and posterior (c) oblique VR images show that the LAD artery (long thin arrows in b, white arrows in c) courses along the anterior interventricular groove, and that the LCx artery (long thick arrow in b, large black arrow in c) courses in the left arterioventricular groove. Obtuse marginal branches (arrowheads) and diagonal branches (short arrows) are also seen.
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Figure 3b. Normal ECG-gated multi–detector row CT anatomy of the LCA and its branches. A = aorta, PA = pulmonary artery. (a) Oblique VR image of the top of the heart shows the LCA (curved arrow) arising from the left sinus of Valsalva and trifurcating into the LAD artery (thin straight arrow), the LCx artery (thick straight arrow), and the ramus intermedius (arrowhead), which takes a course similar to that of the usual first diagonal branch. The LAD artery then gives rise to diagonal branches (short arrows) to the anterior free wall of the left ventricle. (b, c) Anterior (b) and posterior (c) oblique VR images show that the LAD artery (long thin arrows in b, white arrows in c) courses along the anterior interventricular groove, and that the LCx artery (long thick arrow in b, large black arrow in c) courses in the left arterioventricular groove. Obtuse marginal branches (arrowheads) and diagonal branches (short arrows) are also seen.
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Figure 3c. Normal ECG-gated multi–detector row CT anatomy of the LCA and its branches. A = aorta, PA = pulmonary artery. (a) Oblique VR image of the top of the heart shows the LCA (curved arrow) arising from the left sinus of Valsalva and trifurcating into the LAD artery (thin straight arrow), the LCx artery (thick straight arrow), and the ramus intermedius (arrowhead), which takes a course similar to that of the usual first diagonal branch. The LAD artery then gives rise to diagonal branches (short arrows) to the anterior free wall of the left ventricle. (b, c) Anterior (b) and posterior (c) oblique VR images show that the LAD artery (long thin arrows in b, white arrows in c) courses along the anterior interventricular groove, and that the LCx artery (long thick arrow in b, large black arrow in c) courses in the left arterioventricular groove. Obtuse marginal branches (arrowheads) and diagonal branches (short arrows) are also seen.
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Figure 4a. High takeoff of the RCA in a 55-year-old man. On coronal oblique VR (a) and curved maximum-intensity-projection (MIP) (b) images, the RCA demonstrates a high take-off (arrow) above the sinotubular junction. Atherosclerotic change of the RCA with calcified plaque is also demonstrated.
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Figure 4b. High takeoff of the RCA in a 55-year-old man. On coronal oblique VR (a) and curved maximum-intensity-projection (MIP) (b) images, the RCA demonstrates a high take-off (arrow) above the sinotubular junction. Atherosclerotic change of the RCA with calcified plaque is also demonstrated.
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Figure 5. Multiple ostia with separate origins of the RCA and conus branch in a 60-year-old man. Coronal oblique MIP image shows separate ostia of the RCA (curved arrow) and conus branch (straight arrow) from the right coronary sinus.
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Figure 6a. Multiple ostia with separate origins of the LAD and LCx arteries in a 50-year-old man. Coronal oblique MIP image (a) and oblique VR image of the top of the heart (b) show separate ostia of the LAD (straight arrow) and LCx (curved arrow) arteries. Intimal calcification at the os of the LAD artery is also demonstrated. A = aorta, PA = pulmonary artery.
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Figure 6b. Multiple ostia with separate origins of the LAD and LCx arteries in a 50-year-old man. Coronal oblique MIP image (a) and oblique VR image of the top of the heart (b) show separate ostia of the LAD (straight arrow) and LCx (curved arrow) arteries. Intimal calcification at the os of the LAD artery is also demonstrated. A = aorta, PA = pulmonary artery.
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Figure 7a. Single coronary artery in a 55-year-old man. (a) Oblique VR image shows an anomalous origin for the RCA (curved arrow), which arises from the LAD artery (straight arrow) and courses anterior to the pulmonary artery (PA). A = aorta. (b) Coronary angiogram shows the anomalous origin of the hypoplastic RCA (curved arrow) from the LAD artery (straight arrow).
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Figure 7b. Single coronary artery in a 55-year-old man. (a) Oblique VR image shows an anomalous origin for the RCA (curved arrow), which arises from the LAD artery (straight arrow) and courses anterior to the pulmonary artery (PA). A = aorta. (b) Coronary angiogram shows the anomalous origin of the hypoplastic RCA (curved arrow) from the LAD artery (straight arrow).
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Figure 8a. Single coronary artery in an 80-year-old man. (a) Oblique VR image of the top of the heart shows only one coronary artery arising from the left coronary sinus (arrowhead). Note that the RCA (arrow) courses between the aorta (A) and the pulmonary artery (PA). (b) On a sagittal oblique VR image, the single coronary artery demonstrates a high takeoff (arrowhead) above the sinotubular junction. A = aorta, PA = pulmonary artery.
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Figure 8b. Single coronary artery in an 80-year-old man. (a) Oblique VR image of the top of the heart shows only one coronary artery arising from the left coronary sinus (arrowhead). Note that the RCA (arrow) courses between the aorta (A) and the pulmonary artery (PA). (b) On a sagittal oblique VR image, the single coronary artery demonstrates a high takeoff (arrowhead) above the sinotubular junction. A = aorta, PA = pulmonary artery.
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Figure 9a. Bland-White-Garland syndrome in a 29-year-old woman. A = aorta, PA = pulmonary artery. (a) Preoperative anterior oblique VR image shows a dilated RCA (arrow) and the LAD artery with multiple collateral vessels at the right ventricular wall (arrowheads). (b, c) Preoperative VR images (cardiac chambers removed with manual editing) clearly demonstrate the anomalous origin of the LCA (arrow in b, straight arrow in c) from the pulmonary trunk, along with multiple collateral vessels within the interventricular septum (arrowheads in b) and the dilated RCA (curved arrow in c). (d, e) Postoperative VR images, obtained after ligation of the original os of the LCA from the pulmonary trunk and creation of an anastomosis between the left internal mammary artery (short straight arrows) and the LCA (long straight arrow), demonstrate a decrease in the size of the RCA (curved arrow) and markedly diminished collateral vessels in the interventricular septum and right ventricular wall (*).
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Figure 9b. Bland-White-Garland syndrome in a 29-year-old woman. A = aorta, PA = pulmonary artery. (a) Preoperative anterior oblique VR image shows a dilated RCA (arrow) and the LAD artery with multiple collateral vessels at the right ventricular wall (arrowheads). (b, c) Preoperative VR images (cardiac chambers removed with manual editing) clearly demonstrate the anomalous origin of the LCA (arrow in b, straight arrow in c) from the pulmonary trunk, along with multiple collateral vessels within the interventricular septum (arrowheads in b) and the dilated RCA (curved arrow in c). (d, e) Postoperative VR images, obtained after ligation of the original os of the LCA from the pulmonary trunk and creation of an anastomosis between the left internal mammary artery (short straight arrows) and the LCA (long straight arrow), demonstrate a decrease in the size of the RCA (curved arrow) and markedly diminished collateral vessels in the interventricular septum and right ventricular wall (*).
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Figure 9c. Bland-White-Garland syndrome in a 29-year-old woman. A = aorta, PA = pulmonary artery. (a) Preoperative anterior oblique VR image shows a dilated RCA (arrow) and the LAD artery with multiple collateral vessels at the right ventricular wall (arrowheads). (b, c) Preoperative VR images (cardiac chambers removed with manual editing) clearly demonstrate the anomalous origin of the LCA (arrow in b, straight arrow in c) from the pulmonary trunk, along with multiple collateral vessels within the interventricular septum (arrowheads in b) and the dilated RCA (curved arrow in c). (d, e) Postoperative VR images, obtained after ligation of the original os of the LCA from the pulmonary trunk and creation of an anastomosis between the left internal mammary artery (short straight arrows) and the LCA (long straight arrow), demonstrate a decrease in the size of the RCA (curved arrow) and markedly diminished collateral vessels in the interventricular septum and right ventricular wall (*).
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Figure 9d. Bland-White-Garland syndrome in a 29-year-old woman. A = aorta, PA = pulmonary artery. (a) Preoperative anterior oblique VR image shows a dilated RCA (arrow) and the LAD artery with multiple collateral vessels at the right ventricular wall (arrowheads). (b, c) Preoperative VR images (cardiac chambers removed with manual editing) clearly demonstrate the anomalous origin of the LCA (arrow in b, straight arrow in c) from the pulmonary trunk, along with multiple collateral vessels within the interventricular septum (arrowheads in b) and the dilated RCA (curved arrow in c). (d, e) Postoperative VR images, obtained after ligation of the original os of the LCA from the pulmonary trunk and creation of an anastomosis between the left internal mammary artery (short straight arrows) and the LCA (long straight arrow), demonstrate a decrease in the size of the RCA (curved arrow) and markedly diminished collateral vessels in the interventricular septum and right ventricular wall (*).
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Figure 9e. Bland-White-Garland syndrome in a 29-year-old woman. A = aorta, PA = pulmonary artery. (a) Preoperative anterior oblique VR image shows a dilated RCA (arrow) and the LAD artery with multiple collateral vessels at the right ventricular wall (arrowheads). (b, c) Preoperative VR images (cardiac chambers removed with manual editing) clearly demonstrate the anomalous origin of the LCA (arrow in b, straight arrow in c) from the pulmonary trunk, along with multiple collateral vessels within the interventricular septum (arrowheads in b) and the dilated RCA (curved arrow in c). (d, e) Postoperative VR images, obtained after ligation of the original os of the LCA from the pulmonary trunk and creation of an anastomosis between the left internal mammary artery (short straight arrows) and the LCA (long straight arrow), demonstrate a decrease in the size of the RCA (curved arrow) and markedly diminished collateral vessels in the interventricular septum and right ventricular wall (*).
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Figure 10. Drawings illustrate an LCA anomalously arising from the right coronary sinus (R) and four anomalous courses: interarterial (between the aorta and the pulmonary artery [PA]) (A), retroaortic (B), prepulmonic (C), and septal (subpulmonic [beneath the right ventricular outflow tract]) (D). L = left coronary sinus, N = noncoronary sinus.
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Figure 11a. RCA arising from the left coronary sinus and taking an interarterial course in a 44-year-old man. (a) VR image of the top of the heart shows both the RCA (straight arrow) and the LCA (curved arrow) originating from the left coronary sinus. The RCA courses between the pulmonary artery (PA) and the aorta (A). Note the slit-like ostium (arrowhead) of the RCA. (b) Aortic root angiogram shows the anomalous origin of the RCA (arrow), but the exact location of the ostium is not identified.
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Figure 11b. RCA arising from the left coronary sinus and taking an interarterial course in a 44-year-old man. (a) VR image of the top of the heart shows both the RCA (straight arrow) and the LCA (curved arrow) originating from the left coronary sinus. The RCA courses between the pulmonary artery (PA) and the aorta (A). Note the slit-like ostium (arrowhead) of the RCA. (b) Aortic root angiogram shows the anomalous origin of the RCA (arrow), but the exact location of the ostium is not identified.
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Figure 12a. LCA arising from the right coronary sinus and taking a prepulmonic course in a 50-year-old man. (a) Axial oblique VR image shows the LCA (arrows) originating from the right coronary sinus and taking a prepulmonic course, passing anterior to the pulmonary artery (PA). A = aorta. (b) Oblique MIP image shows the separate origins of the LCA (arrows) and RCA (arrowhead) from the right coronary sinus, as well as the prepulmonic course of the LCA.
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Figure 12b. LCA arising from the right coronary sinus and taking a prepulmonic course in a 50-year-old man. (a) Axial oblique VR image shows the LCA (arrows) originating from the right coronary sinus and taking a prepulmonic course, passing anterior to the pulmonary artery (PA). A = aorta. (b) Oblique MIP image shows the separate origins of the LCA (arrows) and RCA (arrowhead) from the right coronary sinus, as well as the prepulmonic course of the LCA.
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Figure 13a. LCx artery arising from the right coronary sinus and taking a retroaortic course in a 45-year-old woman. VR image of the top of the heart (a) and coronary angiogram (b) show the LCx artery (straight arrow) originating from the right coronary sinus and passing behind the aorta (A). The RCA (curved arrow) demonstrates its normal origination from the right coronary sinus. PA = pulmonary artery.
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Figure 13b. LCx artery arising from the right coronary sinus and taking a retroaortic course in a 45-year-old woman. VR image of the top of the heart (a) and coronary angiogram (b) show the LCx artery (straight arrow) originating from the right coronary sinus and passing behind the aorta (A). The RCA (curved arrow) demonstrates its normal origination from the right coronary sinus. PA = pulmonary artery.
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Figure 14a. LAD artery arising from the right coronary sinus and taking a septal (subpulmonic) course in a 65-year-old man. (a) Coronal oblique VR image demonstrates both the LAD artery (long straight arrow) and the RCA (curved arrow) originating from the right coronary sinus. The LAD artery takes an intramuscular course beneath the right ventricular outflow tract (removed with manual editing). The LCx artery (short straight arrow) demonstrates its normal origination from the left coronary sinus. A = aorta. (b) Oblique MIP image reveals the unusual intramuscular course (arrowheads) of the proximal LAD artery, which emerges to the epicardial surface from the myocardium at the level of the middle portion of the artery. Arrow indicates the RCA. LV = left ventricle, PA = pulmonary artery. (c) Coronary angiogram shows a common origin for the LAD artery (straight arrow) and the RCA (curved arrow).
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Figure 14b. LAD artery arising from the right coronary sinus and taking a septal (subpulmonic) course in a 65-year-old man. (a) Coronal oblique VR image demonstrates both the LAD artery (long straight arrow) and the RCA (curved arrow) originating from the right coronary sinus. The LAD artery takes an intramuscular course beneath the right ventricular outflow tract (removed with manual editing). The LCx artery (short straight arrow) demonstrates its normal origination from the left coronary sinus. A = aorta. (b) Oblique MIP image reveals the unusual intramuscular course (arrowheads) of the proximal LAD artery, which emerges to the epicardial surface from the myocardium at the level of the middle portion of the artery. Arrow indicates the RCA. LV = left ventricle, PA = pulmonary artery. (c) Coronary angiogram shows a common origin for the LAD artery (straight arrow) and the RCA (curved arrow).
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Figure 14c. LAD artery arising from the right coronary sinus and taking a septal (subpulmonic) course in a 65-year-old man. (a) Coronal oblique VR image demonstrates both the LAD artery (long straight arrow) and the RCA (curved arrow) originating from the right coronary sinus. The LAD artery takes an intramuscular course beneath the right ventricular outflow tract (removed with manual editing). The LCx artery (short straight arrow) demonstrates its normal origination from the left coronary sinus. A = aorta. (b) Oblique MIP image reveals the unusual intramuscular course (arrowheads) of the proximal LAD artery, which emerges to the epicardial surface from the myocardium at the level of the middle portion of the artery. Arrow indicates the RCA. LV = left ventricle, PA = pulmonary artery. (c) Coronary angiogram shows a common origin for the LAD artery (straight arrow) and the RCA (curved arrow).
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Figure 15a. Myocardial bridging in a 50-year-old man. (a, b) ECG-gated multi–detector row CT scans (short-axis two-chamber views) obtained during the diastolic (a) and systolic (b) phases show luminal narrowing of the intramyocardial segment of the LAD artery during the systolic phase (arrow). (c, d) Coronary angiograms obtained during the diastolic (c) and systolic (d) phases demonstrate the typical milking effect caused by systolic compression of the tunneled segment of the LAD artery (arrowheads).
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Figure 15b. Myocardial bridging in a 50-year-old man. (a, b) ECG-gated multi–detector row CT scans (short-axis two-chamber views) obtained during the diastolic (a) and systolic (b) phases show luminal narrowing of the intramyocardial segment of the LAD artery during the systolic phase (arrow). (c, d) Coronary angiograms obtained during the diastolic (c) and systolic (d) phases demonstrate the typical milking effect caused by systolic compression of the tunneled segment of the LAD artery (arrowheads).
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Figure 15c. Myocardial bridging in a 50-year-old man. (a, b) ECG-gated multi–detector row CT scans (short-axis two-chamber views) obtained during the diastolic (a) and systolic (b) phases show luminal narrowing of the intramyocardial segment of the LAD artery during the systolic phase (arrow). (c, d) Coronary angiograms obtained during the diastolic (c) and systolic (d) phases demonstrate the typical milking effect caused by systolic compression of the tunneled segment of the LAD artery (arrowheads).
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Figure 15d. Myocardial bridging in a 50-year-old man. (a, b) ECG-gated multi–detector row CT scans (short-axis two-chamber views) obtained during the diastolic (a) and systolic (b) phases show luminal narrowing of the intramyocardial segment of the LAD artery during the systolic phase (arrow). (c, d) Coronary angiograms obtained during the diastolic (c) and systolic (d) phases demonstrate the typical milking effect caused by systolic compression of the tunneled segment of the LAD artery (arrowheads).
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Figure 16a. Duplication of the LAD artery in a 47-year-old man. (a) Anterior oblique VR image shows a dual LAD artery coursing along the anterior interventricular groove. Although the short LAD artery (short straight arrow) remains and terminates in the anterior interventricular groove, the long LAD artery (long straight arrow) reenters the groove from the anterior wall of the left ventricle. The diagonal branch (curved arrow) does not take this course. A = aorta, PA = pulmonary artery. (b) On a coronary angiogram, the origination of the septal branches (arrowheads) from the two arteries (arrows) proves that the arteries represent a dual LAD artery, not diagonal branches.
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Figure 16b. Duplication of the LAD artery in a 47-year-old man. (a) Anterior oblique VR image shows a dual LAD artery coursing along the anterior interventricular groove. Although the short LAD artery (short straight arrow) remains and terminates in the anterior interventricular groove, the long LAD artery (long straight arrow) reenters the groove from the anterior wall of the left ventricle. The diagonal branch (curved arrow) does not take this course. A = aorta, PA = pulmonary artery. (b) On a coronary angiogram, the origination of the septal branches (arrowheads) from the two arteries (arrows) proves that the arteries represent a dual LAD artery, not diagonal branches.
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Figure 17a. Coronary artery fistula in a 72-year-old woman. Oblique VR image (a) and coronary angiograms (b, c) show multiple tortuous communicating vessels (arrowheads) originating from the RCA (arrow in b) and the proximal LAD artery (arrow in c). The communicating vessels drain into the main pulmonary trunk. Enlargement of the proximal branches of the RCA and of the proximal LAD artery is also noted. A = aorta, PA = pulmonary artery.
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Figure 17b. Coronary artery fistula in a 72-year-old woman. Oblique VR image (a) and coronary angiograms (b, c) show multiple tortuous communicating vessels (arrowheads) originating from the RCA (arrow in b) and the proximal LAD artery (arrow in c). The communicating vessels drain into the main pulmonary trunk. Enlargement of the proximal branches of the RCA and of the proximal LAD artery is also noted. A = aorta, PA = pulmonary artery.
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Figure 17c. Coronary artery fistula in a 72-year-old woman. Oblique VR image (a) and coronary angiograms (b, c) show multiple tortuous communicating vessels (arrowheads) originating from the RCA (arrow in b) and the proximal LAD artery (arrow in c). The communicating vessels drain into the main pulmonary trunk. Enlargement of the proximal branches of the RCA and of the proximal LAD artery is also noted. A = aorta, PA = pulmonary artery.
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Figure 18. Coronary artery anomaly in a 50-year-old woman with corrected transposition of the great vessels. Axial oblique MIP image shows the coronary arteries originating from both aortic sinuses. Note that the aorta (A) is located anterior to and to the left of the pulmonary artery (PA). The ventricles with their respective atrioventricular valves (not shown) were inverted; thus, the distribution of the coronary arteries is reversed, in keeping with the ventricular inversion. The anterior aortic sinus corresponds to the noncoronary sinus. The morphologic LCA (white arrow) arises from the right posterior aortic sinus and supplies the pulmonary ventricle (anatomic left ventricle). The morphologic RCA (black arrow) arises from the left posterior aortic sinus and supplies the systemic ventricle (anatomic right ventricle). Note the prominent conus branches (arrowheads) supplying the muscular infundibulum. No vessel is seen crossing the right atrioventricular groove (such a vessel would correspond to a normal LCx artery).
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Copyright © 2006 by the Radiological Society of North America.
