Dual left anterior descending coronary artery: angiographic description of important variants and surgical implications

Duplication of Left Anterior Descending Artery: A Case Report on a Rare Abnormality

Duplication of the left anterior descending coronary artery (LAD) is a benign condition. The formation of a double LAD is a rare phenomenon among coronary artery anomalies. The categorization of the branching pattern of the LAD has been articulated well in numerous studies, owing to the widespread adoption of computed tomography angiography. Anomalous coronaries are a crucial pathological condition that should be examined. Individuals who are suffering from chest pain should be aware that it can potentially lead to myocardial ischemia, arrhythmia, or sudden cardiac death. Here is a unique case study detailing the diagnosis of dual LAD in a 50-year-old female patient.

Type 4 Dual Left Anterior Descending Artery: A Case Report of a Rare Congenital Coronary Anomaly

Dual left anterior descending artery (LAD) is a rare congenital coronary artery anomaly with a prevalence of approximately 1% in the general population. To date, 10 types of dual LAD artery anomalies have been reported. Among these, type 4 is one of the rarest. Knowledge and recognition of the dual LAD artery are important for correct diagnosis and planning of coronary bypass surgery and percutaneous coronary intervention. We report a case of a 59-year-old male with type 4 dual LAD artery who presented with dyspepsia and sweating for several months and had approximately 50%-70% stenosis in a major diagonal branch off the short LAD artery.

Dual left anterior descending coronary artery and anomalous origin of left circumflex artery: a novel coronary anomaly revealed by CCTA

In the rare coronary anomaly of Dual LAD, two segments of the vessel reside within the anterior interventricular sulcus. In our case, the short LAD originated from the Left Coronary Sinus (LCS), while the long LAD emerged from the Right Coronary Sinus (RCS). The LCx arose from the RCS, and the RCA displayed typical features. This anomaly was deemed incidental, prompting routine follow-up. It underscores the significance of integrating CCTA for a thorough assessment, offering crucial insights for patient management.

Coronary Artery Anomalies - State of the Art Review

Coronary artery anomalies (CAAs) comprise a wide spectrum of anatomic entities, with diverse clinical phenotypes. We present a case of an anomalous right coronary artery arising from the left aortic sinus with an interarterial course, a potentially fatal condition that can precipitate ischemia and sudden cardiac death. CAAs are increasingly detected in adults, mostly as incidental findings in the course of cardiac evaluation. This is due to the expanding use of invasive and noninvasive cardiac imaging, usually in the work-up for possible CAD. The prognostic implications of CAAs in this group of patients remain unclear. In AAOCA patients, appropriate work-up with anatomical and functional imaging should be performed for risk stratification. An individualized approach to management should be adopted, considering symptoms, age, sporting activities and the presence of high-risk anatomical features and physiologic consequences (such as ischemia, myocardial fibrosis, or cardiac arrhythmias) detected on multimodality imaging or other functional cardiac investigations. This comprehensive and up to date review seeks to crystallize current data in the recent literature, and proposes a clinical management algorithm for the clinician faced with the conundrum of managing such conditions.

Atheroprotective effect of myocardial bridge sustains in aging: Autopsy study on subjects with dual left anterior descending coronary artery type 3

BACKGROUND

The atheroprotective role of the myocardial bridge (MB) on a tunneled segment is already demonstrated in subjects with dual left anterior descending coronary artery (dual LAD) type 3 anomaly, but the dynamics of changes and whether this protective effect sustains during aging is unknown.

METHODS

The retrospective autopsy study included cases of dual LAD type 3 anomaly identified over 18 years. The severity grade of atherosclerosis in branches of dual LAD was estimated by microscopy. The Spearman's correlation test and Receiver operator characteristics (ROC) curve analyses were performed to determine the relation of subjects' age with a degree of the protective role of the myocardial bridge.

RESULTS

A total of 32 dual LAD type 3 cases were identified. The systematic heart examination revealed an anomaly prevalence of 2.1%. The age significantly positively correlated with the severity of atherosclerosis in the subepicardial dual LAD branch but not with the severity of atherosclerosis in the intramyocardial dual LAD branch. Subjects aged ≥38 years were likely to have a more severe degree of atherosclerosis in subepicardial than in intramyocardial LAD arteries (AUC 0.81 95% CI 0.59-1; sensitivity 100%, specificity 66.7%). In subjects aged ≥58 years, this difference was likely to be more pronounced (≥2 degree difference; AUC 0.75 95% CI 0.58-0.93; sensitivity 92.9%, specificity 66.7%).

CONCLUSION

The atheroprotective effect of the myocardial bridge on tunneled segments usually becomes evident throughout the second half of the fourth decade of life and is most pronounced after about 60 years and ceases only in some.

The Role of Coronary CT Angiography in the Evaluation of Dual Left Anterior Descending Artery Prevalence and Subtypes: A Retrospective Multicenter Study

BACKGROUND

The aim of this multicenter study was to evaluate the prevalence and features of dual left anterior descending artery (LAD) subtypes using coronary CT angiography (CCTA).

METHODS

A retrospective multicenter analysis of 2083 CCTA from December 2020 to November 2022 was conducted to search for the presence and morphological features of dual LAD. The two classifications used were the updated classification of Spindola-Franco and the Jariwala classification. Statistical tests were conducted to evaluate the prevalence of dual LADs among sexes and its association with angina in patients without significant coronary stenoses and/or associated cardiac anomalies.

RESULTS

Dual LAD was observed in 124 (5.96%) patients analyzed. According to the Spindola-Franco revisited classification, type I dual LAD was the most common (71/124, 57.26%). According to the Jariwala classification, all cases were group I. In the general population, there was a higher prevalence of dual LAD among females (7.3% females vs. 5.1% males; p value: 0.04). No statistically significant difference was found in the prevalence of angina in the dual LAD population compared to the no dual LAD population (2.1% vs. 1.5%; p value: 0.10).

CONCLUSIONS

The acknowledgment and reporting of LAD duplication is helpful for an optimal management of coronary patients with this condition. Dual LAD was more frequent in the female population, mainly not related with angina. Myocardial bridge was more frequent in the dual LAD population than in the no dual LAD population.

Type II single coronary artery from right aortic sinus, retro-aortic left coronary artery and dual LAD: a rare association of coronary arterial variations

PURPOSE

The coronary arterial tree has a wide range of possible benign anatomical variations. It is important to differentiate them from coronary arterial anomalies, which can remain asymptomatic or in some cases lead to sudden death if undiagnosed.

METHODS

A 42-year-old female patient with a transient ST depression in right precordial leads performed an ECG-gated computed tomography angiography with dual layer spectral CT (IQon Elite Spectral CT, Philips, Amsterdam, The Netherlands) at Circolo Hospital of Varese.

RESULTS

A rare variant was observed and studied: a single common trunk arising from the right sinus of Valsalva which branches into a right coronary artery, a left anterior descending artery with malignant course and a left main with a retroaortic course; the left main gives origin to a dual anterior interventricular artery ("Dual LAD") and a left circumflex artery.

CONCLUSIONS

This type of variation was never described in the English literature. Identifying this variant is crucial for potential ischemic complications during sports activities or with the onset of atherosclerotic disease.

Surgical revascularization strategies of CAD involving dual left anterior descending artery

Dual left anterior descending artery (LAD) is not an uncommon coronary artery anomaly. Preoperative identification of this anomaly in patients with coronary artery disease is important to develop strategies to ensure complete revascularization of the LAD territory. From April 1996 through February 2022, more than 16,500 patients underwent isolated coronary artery bypass surgery (CABG) by our team. Retrospective review of the angiographic and operative records of these patients revealed 85 cases with stenosis of the dual LAD system. The incidence of dual LAD in patients undergoing CABG is 0.51%. Among the 85 patients, 59 (69.4%) had stenosis of both long and short LADs, whereas the remaining 26 (30.5%) had stenosis of either of the LADs. Among the 59 patients who had stenosis of both the LADs, 26 (44.1%) received a left internal thoracic artery (LITA) sequential graft to bypass both the LADs and two received a LITA-LITA baby-Y graft. And in 31 (52.5%) patients, the longer LAD was revascularized with LITA and the other LAD with saphenous vein graft.

Dual left anterior descending artery with anomalous left anterior descending artery from pulmonary artery: double trouble

Anomalous origin of left anterior descending artery (LAD) from pulmonary artery (ALADCAPA) with dual LAD from left sinus is an extremely rare coronary anomaly. The diagnostic challenge lies in differentiating this from a coronary cameral fistula. Surgical reimplantation of the anomalous LAD is recommended to prevent the risk of myocardial ischaemia and ventricular arrhythmias.

[Prevalence of coronary anomalies detected by computed tomography at the Instituto Nacional Cardiovascular- INCOR]

Objective

: To determine the prevalence of coronary anomalies (CA) in patients evaluated by 64-detector computed tomography (CT) at the Instituto Nacional Cardiovascular in Peru between 2016 and 2020.

Materials and methods

Retrospective observational study, coronary artery CT scans of 1486 patients were performed on a 64-detector row CT scanner and reviewed in search for coronary anomalies.

Results

The prevalence of CA detected by CT was 4.71% (70 cases) of which 64.3% were male. Abnormalities of origin were the most frequent, of which the origin of a coronary artery from the opposite coronary sinus was the most common (48.6%), with the right coronary being the main anomalous artery (31%), and the main path was interarterial (31%). Anomalous origin of the left main coronary from the pulmonary artery was found in 5 patients. Among the anomalies of the intrinsic coronary arterial anatomy the most frequent was the double left anterior descending artery (10%). Coronary fistulas accounted for 11.4% of cases.

Conclusions

The prevalence of CA detected by 64-detector CT in a Peruvian institute was 4.71%. The most frequent coronary anomaly was the origin of the right coronary artery from the left coronary sinus with interarterial trajectory.

Investigation of the Frequency of Coronary Artery Anomalies in MDCT Coronary Angiography and Comparison of Atherosclerotic Involvement between Anomaly Types

Coronary artery anomalies (CAAs) are rare anatomical variations characterized by abnormal origin, course, or termination of the coronary arteries. This study aims to identify incidental CAAs in patients who underwent multidetector computed tomography coronary angiography (MDCTCA) to determine their incidence and to evaluate whether there is a difference between CAA types in terms of coronary atherosclerotic involvement. For this purpose, patients who underwent MDCTCA between December 2018 and January 2022 were retrospectively assessed. Of the 5200 MDCTCAs analyzed, CAAs were detected in 136 patients (2.61%). Of these 136 patients, 37 (27.2%) patients had an origin anomaly, 97 (71.3%) had a course anomaly, and 2 (1.5%) had a termination anomaly. There was no statistically significant difference between CAA types in terms of atherosclerotic involvement (p = 0.220). However, atherosclerotic involvement was high in vessels with anomalies when normal vessels with and without anomalies were compared (p = 0.005). Accurate detection of CAAs is vital for endovascular treatment or surgical intervention. MDCTCA is helpful both in the diagnosis of CAA and in the early detection and development of prevention strategies for coronary atherosclerosis.

Dual Left Anterior Descending Artery: Case series based on novel classification and its therapeutic implications

Angiographically, a “dual LAD” is described as two distinct arteries supplying the vascular territory of the LAD in parts, identified as the short LAD/LAD₁ and the long LAD/LAD₂. Using an easy-to-understand three-step approach, Jariwala et al unveiled a novel classification strategy for dual LAD systems in an attempt to decrease ambiguity in diagnosis and management of the anomaly. As part of our research, we looked at a wide range of published cases and case series in the literature, and also those reported from our hospital. In our novel classification system, we divide dual LADs into three main groups based on their origin and vascular territory, each of which is further divided into subgroups based on the course of LAD₁/LAD₂ and the variable feature that is a distinguishing attribute of the type of anomaly to be specified.

A review of 144 publications in the world literature revealed 340 patients eligible for the study. The median age was 58.8 years (SD - 11.42; range - 29–89) with male predominance (3.3:1). Cases in Group I comprised 60.6% of the total cases, followed by Group II (36.2%), and Group III (3.2%). Subgroup I-A was the most common in terms of dual LAD, followed by subgroup II-A. Acute coronary syndrome (45.5%) and chronic coronary syndrome (55.8%) were the most common clinical presentations in patients with significant coronary artery disease (30.8%).

Surgical revascularization of a rare type IV dual left anterior descending artery—a case report

Background

Type IV dual left anterior descending artery (LAD) is a rare congenital coronary anomaly. Though benign with most of the patients being asymptomatic, knowledge of its existence and identification during coronary angiography is important during coronary interventions and surgical revascularization.

Case presentation

We present a rare case of type IV dual left anterior descending artery (LAD) with anomalous origin of one of the two vessels from the right coronary sinus. A 49-year-old female presented with inferior wall infarction and she underwent coronary angiography. Coronary angiogram showed triple vessel coronary artery disease. This rare variant of dual LAD was identified and was confirmed intra-operatively. The patient underwent coronary revascularization with grafts to both the LAD systems.

Conclusions

Proper assessment of the angiogram and knowledge of the coronary anomalies is required during surgical revascularization and percutaneous coronary interventions. This rare anomaly can be missed due to the anomalous origin of the LAD from the right coronary sinus. The identification of the dual LAD and grafting of both the LAD systems is required to achieve complete revascularization.

A very rare coronary artery anomaly: Twin circumflex arteries associated with acute coronary syndrome - two cases report

Circumflex coronary artery anomalies are the most common type so far observed. However, a dual origin of the circumflex is an extremely rare anomaly. We describe two different patients admitted to our clinic with acute coronary syndrome at the same day. Angiography revealed twin circumflex arteries: one from the left main artery and the other from the proximal right coronary artery.

Patient with Acute Coronary Syndrome in the Setting of an Extremely Rare form of Complex Congenital Anomalous Coronaries

A single coronary artery is an exceedingly rare anomaly. Hereby, we present an unusual case of a young patient with an acute coronary syndrome who was found to have a single coronary artery originating from a single ostium in the right sinus of Valsalva with dual left anterior descending (LAD) arteries arising from the right coronary artery with two different anatomical courses, and additionally one of those LADs running a malignant intra-arterial course.

Type X dual left anterior descending (LAD) artery masquerading as type 1 LAD — a case report

Background

Dual left anterior descending (LAD) coronary artery is a rare congenital anomaly. To date, eleven variants of dual LAD have been described with three published reports of type X dual LAD. Here, we describe a new variant of type X dual LAD with a short LAD artery masquerading as type 1 LAD.

Case presentation

A 42-year hypertensive female presented with recent onset angina with a treadmill test positive for inducible ischemia. Coronary angiography showed a normal right coronary artery (RCA). The left main coronary artery (LMCA) originated from the left sinus of Valsalva (SOV), giving rise to a LAD and the left circumflex artery (LCX). Appearing a normal angiogram with type 1 LAD based on its length, the presence of a large bare area in LAD territory (especially at the apex) and lack of septal branches prompted a search for an additional vessel. Right SOV injection showed a vessel originating separately from RCA, which was confirmed to be a long LAD on selective injection, with a pre-pulmonic course and giving rise to septal branches exclusively before wrapping around the apex. Computed tomography coronary angiography (CTCA) confirmed the pre-pulmonic course of long LAD, defined its entry to the distal interventricular septum to the right of short LAD, and ruled out other coronary artery anomalies. In the absence of a stenotic lesion in the epicardial coronaries, angina in our case was presumed to be due to microvascular dysfunction. She was discharged on beta-blocker therapy for co-existing hypertension and is asymptomatic on follow-up at one year.

Conclusions

A short LAD artery of type X Dual LAD could be potentially misdiagnosed as type 1 LAD based on its length. However, an active search for a long LAD could properly diagnose the case as a variant of type X dual LAD, which has important clinical implications. Its awareness is critical for cardiologists and cardiac surgeons to correctly interpret the coronary angiogram and plan proper management.

Prevalence Rates of Congenital Coronary Anomalies and Coronary Variations in Adult Indian Population Using Dual-Source Computed Tomography Coronary Angiography: Analysis of Regional Distribution of Coronary Anomalies and the Need for Standardized Reporting Formats

Background  Congenital coronary artery anomalies (CCAA) are predominantly discovered as incidental findings on computed tomography coronary angiography (CTCA) of adults. They are rare but significant, considering their importance during endovascular or surgical interventions. This study describes the prevalence of CCAA and coronary variants (CV) in adults as identified by CTCA.

Methods  It is a retrospective evaluation of 7,694 CTCAs of adults performed in a tertiary care facility in North India.

Results  CCAA and CV were observed in a total of 9.6% of patients. The most common CV was myocardial bridging, observed in 7.1%. Anomalies of origin and course were detected in 2.3% of the patients. The frequency of these anomalies in the right coronary artery, left main, left circumflex artery, and the left anterior descending artery arteries were 1.06, 0.41, 0.03, and 0.38%, respectively. The single coronary pattern was seen in 0.05% and coronary artery fistulas in 0.03%. Scrutiny of data on Indian regional distribution revealed differing definitions and inclusion and exclusion criteria, making comparisons difficult, highlighting the need for uniform definitions as well as the need to adopt a standardized reporting template and format.

Conclusion  The prevalence of CCAA and CV is 9.6% in adult Indian patients undergoing CTCA. Prior knowledge of these anatomical finding can prevent a catastrophe during surgery or endovascular interventions. Hence, it is important that clinicians, as well as radiologists, are aware of these entities.

"Two for One", Novel Dual Left Anterior Descending Artery (LAD) Variant: Type XIII

Dual left anterior descending artery (LAD) is a rare phenomenon that occurs in less than one percent of the population. To date, 12 variants have been identified. Proper identification of coronary vessels is crucial in emergent situations that require prompt action, such as percutaneous coronary intervention (PCI). We propose that our case highlights a novel 13th (type XIII) variant. We present the case of a 57-year-old African American woman with a past medical history of hypertension, glaucoma, cerebral vascular accident, dyslipidemia who presented to the ED complaining of atypical chest pain for one day duration. Electrocardiography showed normal sinus rhythm at 60 beats per minute (bpm), normal axis, normal intervals, no acute ischemic changes, and an isolated T wave inversion in DIII. Cardiac markers were within normal limits. The patient was started on aspirin 81mg, atorvastatin 40mg, and restarted on amlodipine 5mg. Echocardiography showed a left ventricular ejection fraction (LVEF): 65%, normal right ventricular size and systolic function, mild mitral valve regurgitation, and mild aortic regurgitation. Computed tomographic (CT) angiography showed a novel subtype of dual LAD, the left circumflex and right coronary arteries were patent. The patient was discharged once stabilized and advised to follow up with cardiology. Dual LAD describes a rare anatomic variant in which two coronary branches, known as short and long LAD arteries, supply the territory normally supplied by the solitary LAD artery. To date, 12 variants of dual LAD, classified by origin and course of the short and long LAD arteries, have been described in the literature. To the best of our knowledge, the current case describes a novel subtype of dual LAD, variant XIII. The LAD originates as usual from the left main coronary artery (LMCA) and initially runs in the anterior interventricular groove for a short course before bifurcating into two long LADs which both leave the interventricular groove and course out to the apex. One of the vessels courses laterally and the other courses medially of the interventricular groove. It is pertinent to identify the coronary vessels accurately before certain interventions are taken. Acknowledgement of this phenomenon can help guide accurate management in the future for patients with this condition.

Prevalence and Pattern of Congenital Coronary Artery Anomalies in Patients Undergoing Coronary Angiography at a Tertiary Care Hospital of Northern India

Objectives: To evaluate the prevalence and pattern of congenital coronary artery anomalies (CAAs) in the adult population undergoing catheter coronary angiography.

Methods: The coronary angiograms done between October 2015 and September 2020 were reviewed for the presence of coronary anomalies based upon Angelini's classification. The medical record of patients with anomalies was reviewed for symptomatology and indication of angiography.

Results: CAAs were found in 129 (87 males and 42 females) of 6,258 patients giving a prevalence of 2.06%. The mean age was 57.8 ± 11.8 (range 32-81) years. Among these, the anomalous origin and course of the coronaries were the most common anomaly seen in 81 (1.29%) patients, followed by intrinsic anomalies of the coronary arterial system in 44 (0.7%) patients and anomalies of coronary termination and anomalous anastomotic vessels in 2 (0.03%) patients each. Overall, the absence of the left main trunk with a separate origin of the left anterior descending (LAD) and the circumflex artery was the commonest anomaly seen in 46 (0.74%) patients, followed by dual LAD in 35 (0.56%) patients. The anomalous origin of the right coronary artery (RCA) from the left sinus was seen in 14 patients (0.22%) and that of the circumflex artery from the right sinus or right coronary artery was seen in 11 patients (0.17%). The origin of the left main and RCA from ascending aorta was found in eight (0.13%) patients. One (0.02%) patient had a single coronary artery, and another one (0.02%) had all the three coronary arteries arising from the right sinus; however, with separate ostia. The split RCA was seen in nine (0.14%) patients and there were two (0.03%) patients each of coronary artery fistulae, and of anomalous anastomotic vessels.

Conclusions: The prevalence of congenital coronary anomalies in this study was 2.06%. The commonest anomaly was that of origin and courses of the vessels, however, the pattern of anomalies is different from previous studies.

Cardiac-CT with the newest CT scanners: An incoming screening tool for competitive athletes?

Competitive athletes of all skill levels are at risk of sudden cardiac death (SCD) due to certain heart conditions. Prior to engagement in high-intensity athletics, it is necessary to screen for these conditions in order to prevent sudden cardiac death. Cardiac-CT angiography (CCTA) is a reliable tool to rule out the leading causes of SCD by providing an exceptional overview of vascular and cardiac morphology. This allows CCTA to be a powerful resource in identifying cardiac anomalies in selected patients (i.e. unclear symptoms or findings at ECG or echocardiography) as well as to exclude significant coronary artery disease (CAD). With the advancement of technology over the last few years, the latest generations of computed tomography (CT) scanners provide better image quality at lower radiation exposures. With the amount of radiation exposure per scan now reaching the sub-millisievert range, the number of CT examinations it is supposed to increase greatly, also in the athlete's population. It is thus necessary for radiologists to have a clear understanding of how to make and interpret a CCTA examination so that these studies may be performed in a responsible and radiation conscious manner especially when used in the younger populations. Our work aims to illustrate the main radiological findings of CCTAs and highlight their clinical impact with some case studies. We also briefly describe critical features of state-of-the-art CT scanners that optimize different acquisitions to obtain the best quality at the lowest possible dose.

Congenital Coronary Artery Anomalies: Three Cases and Brief Review of the Literature

Coronary artery anomalies (CAAs) are congenital vascular defects which can remain hidden and asymptomatic over the complete life course of an individual. They are defined as deviations from the normal coronary anatomy regarding the arterial origin, course, or both. Their incidence varies from 1.3% to 5.64% in coronary angiography cohorts, and they can be detected as incidental findings. In certain cases, CAAs can be hemodynamically significant and unfortunately can be proven lethal. Their link with sudden cardiac death, especially in otherwise healthy competitive athletes, is well established, but their prognostic significance, range of symptoms, and pathophysiology remain to be further elucidated. Here, along with a brief review of related literature, we present a series of three cases: one case of an anomalous origin of the right coronary artery (RCA) from the left coronary sinus, one case of a split RCA originating from the left coronary sinus, and one case of a dual left anterior descending (LAD) artery system.

Dual left anterior descending artery: diagnostic criteria and novel classification

Duplication of the left anterior descending artery is an uncommon coronary anomaly. Since no proper classification has been established after the initial description and numerical classification by Spindola-Franco et al., many newer numbers have evolved with many overlapping and unclassified variants described in the literature. Identification and reasonable management strategies for dual left anterior descending artery (LAD) are crucial in preventing the long-term disastrous consequences of inadequate revascularization. Clinicians and diagnosticians should be aware of this specific angiographic-based congenital coronary abnormality of the LAD. We, therefore, sought a new, reasonable classification of the dual LAD system, which would clarify this ambiguity, which also has therapeutic implications.

Coronary artery anomalies and dominance: data from a single center in Turkey

BACKGROUND

Coronary artery anomalies (CAA) are found in 0.2% to 1.3% of coronary angiograms. The aim of the presented study was to describe congenital CAA and their variations, also identifying the prevalence of these anomalies and coronary artery dominance in our center.

METHODS

A total of 7858 patients were included in the study retrospectively between August 2015 and March 2020. Patients undergoing coronary angiography (CAG) were reviewed by at least 2 independent and experienced observers. The Angelini's CAA Classification method was used to classify patients. Coronary dominance was determined according to the artery from which the posterior desending artery originated.

RESULTS

CAA was detected in 88 (1.1%) out of 7858 patients. Of these patients, 73 (82.9%) had anomalies of origination and course called group A, 7 (7.9%) had anomalies of intrinsic coronary arterial anatomy called group B, and 8 (9.1%) had anomalies of coronary termination called group C. Anomalous collateral vessels called group D were not detected. RCA dominance was N.=5579 (70.99%), Cx dominance was N.=1021 (12.99%), and codominancy was N.=1258 (16.01%).

CONCLUSIONS

The incidence of CAA was 1.1% in total and is compatible with other major studies. According to the Angelini CAA clasification, group B anomalies are observed more frequently than other studies. Cx dominance is moderately high.

Surgical management for dual left anterior descending artery with anomalous origin of left coronary artery from pulmonary artery: a case report

A dual left anterior descending artery with an anomalous origin of the left coronary artery from the pulmonary artery is an extremely rare coronary artery anomaly, with only one case known previously reported. However, that study presented coronary anatomical findings with images and little is known regarding patient outcome following surgical management for this unique condition. We present here the first case report of an affected patient, who underwent off-pump coronary artery bypass grafting and ligation of the coronary anomaly, as well as postoperative course details.

Four Coronary Arteries Separately Originating from the Right Sinus of Valsalva

An 82-year-old woman was admitted to our hospital with heart failure. Coronary angiography revealed one anatomically normal right coronary artery and three left coronary arteries (LCA-1, LSA-2, and LSA-3) separately originating from the right sinus of Valsalva, comprising multiple atherosclerotic lesions. LCA-1 became the obtuse marginal branch after branching off into the septal branches. LCA-2 was the main circumflex artery with an obstructive lesion. LCA-3 corresponded to the distal part of the anterior descending branch. The patient died 14 days after hospitalization. We describe the rarity of quadriostial origin, the unusual course, and the unusual branching of the coronary arteries.

Prevalence and morphologic features of dual left anterior descending artery subtypes in coronary CT angiography

OBJECTIVES

The purpose of this study was to identify the prevalence of dual left anterior descending artery and define the morphological features using coronary computed tomography angiography in order to raise awareness of dual left anterior descending artery among radiologists.

MATERIALS AND METHODS

The radiologic reports of 1912 patients who underwent coronary computed tomography angiography at our institution were searched retrospectively for the presence of dual left anterior descending artery. Computed tomography images of patients with dual left anterior descending artery were then reviewed, and the morphological features of dual left anterior descending artery were evaluated.

RESULTS

Dual left anterior descending artery was identified in 1.3% of the patients in this study population. Type 1 dual left anterior descending artery was the most common subtype (76%). Four additional cases that were not classified before were also detected.

CONCLUSION

Dual left anterior descending artery has a variety of subtypes reported mostly as odd cases, and gaining diagnostic awareness of dual left anterior descending artery is more critical, rather than listing and counting the subtypes. With the widespread use of coronary computed tomography angiography, it has become essential for radiologists to have knowledge about dual left anterior descending artery, as it is vital, especially for surgical planning.

Incidence, Characteristics and Atherosclerotic Involvement of Coronary Artery Anomalies in Adult Population Undergoing Catheter Coronary Angiography

Background

Coronary artery anomalies (CAAs) are rare disorders of coronary anatomy with varied clinical presentations. There are widespread geographic variations in incidence and patterns of these anomalies, with limited data from North Indian population. We performed a retrospective study to evaluate the incidence, characteristics and atherosclerotic involvement of CAAs in adult population undergoing catheter coronary angiography.

Methods

Serial coronary angiographies performed at our institution over a period of 2.5 years (from January 2017 to June 2019) were retrospectively analyzed. We identified patients with anomalous coronaries and studied their clinical characteristics and angiographic profiles.

Results

Among 3,233 coronary angiograms analyzed, CAAs were found in 99 patients with an incidence of 3.06%. Mean age of the patients was 56.2 ± 12.9 years (range: 20 - 86 years), with 74.75% being males and 25.25% females. Split right coronary artery (RCA) was the most common coronary anomaly, being seen in 27 patients; with an angiographic incidence of 0.84%. Dual left anterior descending artery (LAD) was the second most common anomaly and was seen in 22 cases with an angiographic incidence of 0.68%. Absent left main trunk was noted in 14 patients (0.43%). Ectopic origin of RCA from left sinus was seen in 12 patients (0.37%), while ectopic origin of RCA from ascending aorta was seen in four patients (0.12%). Ectopic origin of left circumflex artery (LCX) from right sinus or RCA was noted in 13 patients (0.40%). One patient (0.03%) had a superdominant LAD supplying the posterior descending artery (PDA). Coronary artery fistulae were seen in six patients (0.18%). Significant coronary artery disease (CAD) was seen in 89 of 268 (33.21%) normal vessels, whereas it was seen in 56 of 114 (49.12%) of anomalous vessels. This difference was statistically significant (P = 0.003).

Conclusions

The incidence of CAAs in our study was slightly higher than many of the previous angiographic series. The patterns of coronary anomalies in our study were different from most of the previous studies. Our study had higher incidence of atherosclerotic involvement of anomalous vessels as compared to normal vessels.

A rare case of type X dual left anterior descending coronary artery

A dual left anterior descending (LAD) coronary artery is a rare, and benign congenital anomaly. In this anomaly, there is the presence of two LADs in the anterior inter ventricular sulcus (AIVS). One of the LADs is a short one that ends high in the AIVS. The other longer one enters the distal AIVS and feeds the apex. To date, 9 types of dual LAD variants, and one novel type X has been reported. Herein, we report a case of type X dual LAD with a literature review. <Learning objective: Dual left anterior descending coronary artery (LAD) is an important coronary anomaly to be aware of by interventional cardiologists to avoid misinterpretation of coronary angiography and surgical complications related to coronary interventions. We report a new variation of type X dual LAD with a literature review.>.

Prevalence and characteristics of dual left anterior descending artery in adult patients undergoing coronary angiography

Aim: To determine the prevalence and characteristics of dual left anterior descending artery (LAD) in adults undergoing catheter coronary angiography. Materials & methods: We identified cases with dual LAD by retrospectively analyzing 3233 angiograms done from January 2017 to June 2019. Results: Dual LAD was seen in 22 patients (0.68%). We identified type I dual LAD in 14 cases, type II in 7 cases and type III in 1 case. Significant stenosis was seen in proximal part of long LAD in 12 cases, in LAD proper in 7 cases and in proximal part of short LAD in 4 cases. Conclusion: Dual LAD is a rare anomaly. Its sound knowledge is essential for proper management of patients with coronary artery disease.

Coronary Artery Anomalies and Associated Radiologic Findings

Coronary anomalies occur in about 1% of the general population and in severe cases can lead to sudden cardiac death. Coronary computed tomography angiography and magnetic resonance imaging have been deemed appropriate for the evaluation of coronary anomalies by accurately allowing the noninvasive depiction of coronary artery anomalies of origin, course, and termination. The aim of this article is to describe and illustrate a comprehensive array for the classification of coronary artery anomalies.

A New Variant of Dual Left Anterior Descending Artery Anomaly: Type XI

A dual left anterior descending (LAD) artery is a rare congenital anomaly which is classified into different types based on the origin, course and termination of the short and long LAD arteries. To date, 10 variants of dual LAD artery anomalies have been described. We report a 44-year-old woman who was referred to the Department of Radiology, Royal Hospital, Muscat, Oman, in 2017. Coronary computed tomography angiography revealed a dual LAD artery anomaly in which the short and long LAD arteries shared a common ostium with the right coronary artery from the right coronary sinus. To the best of the authors' knowledge, this type of variant has not been previously reported in the literature.

Overview of coronary artery variants, aberrations and anomalies

Coronary artery anomalies and variants are relatively uncommon congenital disorders of the coronary artery anatomy and constitute the second most common cause of sudden cardiac death in young competitive athletes. The rapid advancement of imaging techniques, including computed tomography, magnetic resonance imaging, intravascular ultrasound and optical coherence tomography, have provided us with a wealth of new information on the subject. Anomalous origin of a coronary artery from the contralateral sinus is the anomaly most frequently associated with sudden cardiac death, in particular if the anomalous coronary artery has a course between the aorta and the pulmonary artery. However, other coronary anomalies, like anomalous origin of the left coronary artery from the pulmonary artery, atresia of the left main stem and coronary fistulae, have also been implicated in cases of sudden cardiac death. Patients are usually asymptomatic, and in most of the cases, coronary anomalies are discovered incidentally during coronary angiography or on autopsy following sudden cardiac death. However, in some cases, symptoms like angina, syncope, heart failure and myocardial infarction may occur. The aims of this article are to present a brief overview of the diverse coronary variants and anomalies, focusing especially on anatomical features, clinical manifestations, risk of sudden cardiac death and pathophysiologic mechanism of symptoms, as well as to provide valuable information regarding diagnostic workup, follow-up, therapeutic choices and timing of surgical treatment.

Percutaneous coronary intervention in a rare case of Type V dual LAD

Congenital coronary anomalies are rare and reported to occur in 0.64-1.3% of patients undergoing coronary angiography. The dual left anterior descending coronary artery (LAD) is a rare coronary anomaly defined as the presence of two LADs in the anterior interventricular sulcus (AIVS). It consists of a short LAD that ends high in the AIVS and a longer LAD that enters the distal AIVS and feeds apex. Percutaneous interventions are even more uncommon in dual LAD especially Type V LAD. Thus we describe an interesting case of percutaneous transluminal coronary angioplasty (PTCA) with stenting to Type V dual LAD in a patient with chronic stable angina who was refractory to maximal anti-anginal medications. Our case was unique for these aspects - 1)Type V dual LAD is rare.2)Ramus artery is present in fewer cases of dual LAD.3)Long LAD had a myocardial bridge.4)Few cases have been reported of PTCA with stenting to short LAD. <Learning objective: The excerpts which can be taken from this interesting case report are - (1) Always look for the artery supplying the apical area of the heart. (2) If the apical area appears bare on left heart catheterization, then consider a Type I left anterior descending coronary artery (LAD), especially if the RCA territory supplies the apical area or consider a remote possibility of a dual LAD with separate origin of its distal LAD. (3) If in a stress test, the ischemia is localized to the apex then the physicians can consider the anomalous distal LAD to be the culprit vessel in these rare cases. (4) Revascularization of short proximal LAD will benefit the patient in reducing symptomatology if diseased. (5) PTCA with stenting can also be an effective alternative to coronary artery bypass grafting (CABG) in patients with dual LAD.>.

One down, one to go: coronary anomaly dual LAD blood supply with worsening chronic stable angina and 100% occluded left short LAD type IV variant

Although rare, usually asymptomatic, and without concurrent disease, dual left anterior descending arteries (LAD) poses great challenges. We describe a 55-year-old male with no history of coronary disease, who presented with worsening substernal chest pain with exertion, and was ruled out for myocardial infarction. On left heart catheterization and subsequent computed tomography angiogram, he was determined to have a dual LAD with a long LAD emerging from the right coronary artery. Moreover, this long LAD gave collaterals to a native long diagonal that ran parallel to this vessel from the left system and was chronically occluded. The long LAD, consistent with type IV classification, traveled in the anterior intraventricular groove to supply left ventricular myocardium; the chronically occluded long left native diagonal supplying lateral walls and apex is a unique variant. It is important to be aware of these anomalies to establish correct diagnoses and determine treatment options.

Type IV dual left anterior descending coronary artery: a case report

Background

Dual left anterior descending (LAD) artery or duplication of LAD is a rarely reported coronary anomaly, consisting of two branches supplying the usual distribution of the LAD. Type IV dual LAD, in which a short LAD arises from the left main coronary artery and a long LAD arises from the right coronary artery is remarkably rare, and has not been reported in a Bangladeshi subject.

Case presentation

We describe the case of a 70-year old Bangladeshi male who presented with breathlessness in the background of a prior inferior myocardial infarction. Coronary angiography revealed an anomalous dual LAD. The short LAD which arose from the left main coronary artery gave off the first septal branch and terminated after giving off a large diagonal branch which continued further down towards the apex. The long LAD arose from the proximal right coronary artery and after traversing a distance, arrived at the interventricular septum, terminating at the apex after giving off diagonal branches. The right coronary artery was totally occluded from its early mid part and well-collateralized with retrograde flow from the left system.

Conclusion

We describe a case with unique variation of dual LAD type IV, which has previously not been described in a Bangladeshi subject thus far. Coronary angiography is vital to determine this coronary anomaly, which is usually detected incidentally on routine angiography for chest pain, sometimes with involvement of significant lesion of other coronary arteries, as in this case.

Synchronisation between contrast media administration and caudocranial scan direction increases visualisation of altered coronary artery blood flow in patients presenting with dual left anterior descending coronary artery

Coronary CT angiography (CCTA) has the advantage over invasive coronary angiography in that its non-invasive nature and minimal risk on patients. CCTA enables accurate assessment of the entire heart, coronary artery system and thorax, displaying three-dimensional information about the spatial relations of the anomalous vessels and surrounding intraluminal and extraluminal anatomy, and thereby contributing clinically important prognostic information. Dual left anterior descending (LAD) coronary artery consists of of two LAD arteries within the anterior interventricular sulcus (AIVS). Type 4 is infrequently reported subtype and differs from the others, with a long LAD originating from the right coronary artery (Mercado, A., Johnson Jr, G., Calver, D., & Sokol, R. J. (1989). Cocaine, pregnancy, and postpartum intracerebral hemorrhage. Obstetrics & Gynecology, 73(3, Part 2), 467-468. and the short LAD originating from the left main coronary artery. However, the radiological features between the short LAD and septal coronary arteries remain a controversy, with the latter being determined by CCTA. We present a case report based on short LAD terminating proximally in the AIVS and the long LAD originating from the RCA and terminating into the distal AIVS with the later having a long septal travelling parallel to the long LAD.

Successful Restoration of Complete Heart Block to Normal Sinus Rhythm by Primary Angioplasty of Dual Left Anterior Descending Artery

Dual left anterior descending (LAD) artery is a rare coronary anomaly. We present a patient with a rare case of dual LAD, smaller one arising from the left main coronary stem and larger one from right coronary artery who presented with acute anterior wall myocardial infarction with complete heart block (CHB). Temporary pacemaker was implanted and coronary angiogram revealed critical occlusion of proximal LAD which was subsequently revascularized by primary angioplasty using drug-eluting stent (Xience prime, 2.75 × 23 mm) leading to recovery of CHB and restoration to normal rhythm. To the best of our knowledge, this is the first reported case of dual LAD presenting with CHB treated by primary angioplasty reported in the literature.