
Anomalous Origin of Right Coronary Artery from Ascending Aorta: MDCT Coronary Angiography Depiction Images
TJ01-TJ02
Correspondence
Dr. Senthil Kumar Aiyappan,
Professor and Head, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre, Chengalpattu-603203, Tamil Nadu, India.
E-mail: asenthilkumarpgi@gmail.com
A 46-year-old male presented with complaints of chest pain and dyspnoea on moderate exertion for the past month. The patient was a known case of type 2 diabetes mellitus and hypertension, and has been on treatment for the past five years. He was not a smoker or alcoholic. Suspecting coronary artery disease, a diagnostic work-up was performed. Blood investigations revealed dyslipidaemia. Electrocardiography (ECG) showed sinus rhythm with a limited right bundle branch block with ST-T changes. Echocardiogram showed biventricular dysfunction. Since the patient was reluctant to undergo catheter coronary angiography, a Computed Tomography (CT) Coronary angiogram was performed first. A 128-slice Multidetector Computed Tomography (MDCT) coronary angiography revealed an anomalous high origin of the Right Coronary Artery (RCA) arising from the anterior wall of the ascending aorta approximately 2 cm above the sinotubular junction at an acute angle of 45° (Table/Fig 1),(Table/Fig 2) [Video-1]. The anomalous RCA followed its normal course without any intramural course noted. Mixed plaques were observed in the RCA, with involvement distal to the acute marginal artery, causing a maximum of 90% stenosis or complete occlusion. The Left Coronary Artery (LCA) was found to be normal, arising from the left cusp of the coronary sinus and dividing into the left anterior descending artery and left circumflex artery. The left anterior descending artery showed significant stenosis in its proximal third. The left circumflex artery exhibited minimal coronary artery disease with no significant stenosis. Therefore, double-vessel coronary artery disease was diagnosed, and the patient was advised to undergo a revascularisation procedure. Currently, the patient is on medication and undergoing follow-up.
The anomalous origin of the RCA was first described by White and Edwards in 1948 (1). The incidence of an anomalous RCA varies from 0.026 to 0.25% (1). Patients with an anomalous origin of the RCA can be asymptomatic or may present with angina, myocardial ischaemia, or sudden cardiac death (1),(2). Possible causes can include narrow ostia, a malignant course leading to its compression between the aorta and pulmonary artery, or spasm due to compression in its malignant course. In index case, the patient’s symptoms were due to coronary artery disease and not an anomalous RCA. Anomalous RCA origin from the ascending aorta is an extremely rare anomaly comprising only 0.04 to 0.15% of all reported anomalies (3). In a case reported by Ramirez Damera R et al., there was an anomalous origin of the RCA from the ascending aorta above the left sinus of Valsalva; however, in index case, it arose from the anterior wall of the ascending aorta above the sinotubular junction (3). In a recent case reported by Mutluoglu M et al., the anomalous RCA had a high origin from the ascending thoracic aorta above the sinotubular junction, similar to index case (4). Cannulation of the anomalous RCA can be difficult and requires extra effort during catheter coronary angiogram. If found incidentally and asymptomatic, only careful follow-up is recommended.