Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website http://www.cardiologyres.org

Original Article

Volume 10, Number 6, December 2019, pages 358-368

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

Figure 1. Coronary angiogram in right anterior oblique (RAO) caudal projection showing absent left main trunk with separate origin of left anterior descending artery (LAD) and left circumflex (LCX) from left sinus.

Figure 2. Coronary angiogram in left anterior oblique (LAO) projection showing origin of right coronary artery (RCA) from left sinus. RCA had critical stenosis in mid segment with slow flow.

Figure 3. Coronary angiogram in left anterior oblique (LAO) projection showing origin of right coronary artery (RCA) from ascending aorta.

Figure 4. Coronary angiogram in left anterior oblique (LAO) projection showing ectopic origin of left circumflex artery (LCX) from right sinus.

Figure 5. Coronary angiogram in anterior-posterior (AP) cranial projection showing split right coronary artery (RCA).

Figure 6. Coronary angiogram in right anterior oblique (RAO) cranial projection showing type I dual left anterior descending artery (LAD).

Figure 7. Coronary angiogram in right anterior oblique (RAO) cranial projection showing superdominant left anterior descending artery (LAD) continuing as posterior descending artery (PDA). Temporary pacing lead is seen in right ventricle (RV) apex as patient had third degree atrioventricular (AV) block.

Figure 8. Coronary angiogram in left anterior-oblique (LAO) projection showing fistula from proximal right coronary artery (RCA), draining into right atrium (RA).

**Table 1.** Angelini Classification System for Coronary Anomalies
LAD: left anterior descending artery; RCA: right coronary artery; LCA: left coronary artery.
Anomalies of origin and course
Absent left main trunk
Anomalous location of coronary ostium within aortic root or adjacent to proper aortic sinus
Anomalous location of coronary ostium outside normal coronary sinuses
Anomalous location of coronary ostium at improper sinus
Single coronary artery
Anomalies of intrinsic coronary arterial anatomy
Congenital ostial stenosis or atresia
Coronary ostial dimple
Coronary ectasia or aneurysm
Absent coronary artery
Coronary hypoplasia
Intramural coronary artery (myocardial bridging)
Subendocardial coronary course
Coronary crossing
Anomalous origin of posterior descending artery from LAD or from a septal branch
Split RCA
Split LAD/dual LAD
Ectopic origination of first septal branch
Anomalies of coronary termination
Inadequate arteriolar/capillary ramifications
Fistulas from RCA, LCA, or conus artery
Anomalous anastomotic vessels

Table 1. Angelini Classification System for Coronary Anomalies

LAD: left anterior descending artery; RCA: right coronary artery; LCA: left coronary artery.

Anomalies of origin and course

Absent left main trunk

Anomalous location of coronary ostium within aortic root or adjacent to proper aortic sinus

Anomalous location of coronary ostium outside normal coronary sinuses

Anomalous location of coronary ostium at improper sinus

Single coronary artery

Anomalies of intrinsic coronary arterial anatomy

Congenital ostial stenosis or atresia

Coronary ostial dimple

Coronary ectasia or aneurysm

Absent coronary artery

Coronary hypoplasia

Intramural coronary artery (myocardial bridging)

Subendocardial coronary course

Coronary crossing

Anomalous origin of posterior descending artery from LAD or from a septal branch

Split RCA

Split LAD/dual LAD

Ectopic origination of first septal branch

Anomalies of coronary termination

Inadequate arteriolar/capillary ramifications

Fistulas from RCA, LCA, or conus artery

Anomalous anastomotic vessels

**Table 2.** Clinical Characteristics of 99 Patients With Coronary Anomalies
Clinical characteristics	N (%)
LV: left ventricle.
Gender
Male	74 (74.75%)
Female	25 (25.25%)
Indication for coronary angiography
Acute coronary syndromes	43 (43.43%)
Stable ischemic heart disease (angina/dyspnea on exertion)	25 (25.25%)
Atypical chest pain with Electrocardiographic/ Echocardiographic changes	22 (22.22%)
Heart failure or LV dysfunction	7 (7.07%)
Workup prior to pacemaker implantation	2 (2.02%)
Risk factors
Hypertension	41 (41.41%)
Diabetes mellitus	33 (33.33%)
Dyslipidemia	19 (19.19%)
Smoking	26 (26.26%)

Table 2. Clinical Characteristics of 99 Patients With Coronary Anomalies

Clinical characteristics

N (%)

LV: left ventricle.

Gender

Male

74 (74.75%)

Female

25 (25.25%)

Indication for coronary angiography

Acute coronary syndromes

43 (43.43%)

Stable ischemic heart disease (angina/dyspnea on exertion)

25 (25.25%)

Atypical chest pain with Electrocardiographic/ Echocardiographic changes

22 (22.22%)

Heart failure or LV dysfunction

7 (7.07%)

Workup prior to pacemaker implantation

2 (2.02%)

Risk factors

Hypertension

41 (41.41%)

Diabetes mellitus

33 (33.33%)

Dyslipidemia

19 (19.19%)

Smoking

26 (26.26%)

**Table 3.** Incidence and Patterns of Coronary Anomalies in Our Study
Anomaly	N	Incidence (%)	Anomaly (%)
^aUsually benign. ^bPotentially serious. ^cSmall fistulae are usually benign, large or multiple fistulae can lead to serious manifestations. LAD: left anterior descending artery; RCA: right coronary artery; LCX: left circumflex artery; PDA: posterior descending artery.
Total coronary angiographies	3,233
Total coronary anomalies	99	3.06
Anomalies of origin and distribution
Absent left main trunk^a	14	0.43	14.14
RCA from left sinus^b	12	0.37	12.12
RCA from ascending aorta^a	4	0.12	4.04
LCX from right sinus/RCA^a	13	0.40	13.13
Anomalies of intrinsic coronary arterial anatomy
Split RCA^a	27	0.84	27.27
Dual LAD^a	22	0.68	22.22
Superdominant LAD supplying PDA^a	1	0.03	1.01
Anomalies of coronary termination
Coronary arterial fistulae^c	6	0.18	6.06

Table 3. Incidence and Patterns of Coronary Anomalies in Our Study

Anomaly

Incidence (%)

Anomaly (%)

^aUsually benign. ^bPotentially serious. ^cSmall fistulae are usually benign, large or multiple fistulae can lead to serious manifestations. LAD: left anterior descending artery; RCA: right coronary artery; LCX: left circumflex artery; PDA: posterior descending artery.

Total coronary angiographies

3,233

Total coronary anomalies

3.06

Anomalies of origin and distribution

Absent left main trunk^a

0.43

14.14

RCA from left sinus^b

0.37

12.12

RCA from ascending aorta^a

0.12

4.04

LCX from right sinus/RCA^a

0.40

13.13

Anomalies of intrinsic coronary arterial anatomy

Split RCA^a

0.84

27.27

Dual LAD^a

0.68

22.22

Superdominant LAD supplying PDA^a

0.03

1.01

Anomalies of coronary termination

Coronary arterial fistulae^c

0.18

6.06

**Table 4.** Atherosclerotic Involvement of Coronary Arteries in Our Study
	Total number	Percentage (%)
CAAs: coronary artery anomalies; CAD: coronary artery disease; LMCA: left main coronary artery.
Total patients with CAAs	99	100
Normal coronaries/insignificant CAD	31	31.31
Significant CAD	68	68.69
Single vessel disease	20	20.20
Double vessel disease	18	18.18
Triple vessel disease	30	30.30
LMCA involvement	1	1.01
Patients with CAD in anomalous vessels	53	53.54
Patients with CAD only in normal vessels	15	15.15
Patients with CAD only in anomalous vessels	11	11.11

Table 4. Atherosclerotic Involvement of Coronary Arteries in Our Study

Total number

Percentage (%)

CAAs: coronary artery anomalies; CAD: coronary artery disease; LMCA: left main coronary artery.

Total patients with CAAs

100

Normal coronaries/insignificant CAD

31.31

Significant CAD

68.69

Single vessel disease

20.20

Double vessel disease

18.18

Triple vessel disease

30.30

LMCA involvement

1.01

Patients with CAD in anomalous vessels

53.54

Patients with CAD only in normal vessels

15.15

Patients with CAD only in anomalous vessels

11.11

**Table 5.** Incidence and Patterns of Coronary Anomalies in Previous Studies
Author/year of publication	Incidence (%)	Most common anomaly	Imaging modality	Country
LM: left main; LAD: left anterior descending artery; LCX: left circumflex artery; RCA: right coronary artery; RCS: right coronary sinus; LCS: left coronary sinus; NCS: non-coronary sinus; CAG: catheter coronary angiography; MDCT: multidetector computed tomography.
Yamanaka et al, 1990 [2]	1.30 (1,686 of 126,595)	Absent LM trunk with separate origin of LAD and LCX	CAG	USA
Kaku et al, 1996 [8]	0.31 (56 of 17,731)	Anomalous origin of RCA from LCS	CAG	Japan
Kardos et al, 1997 [7]	1.34 (103 of 7,694)	Absent LM trunk with separate origin of LAD and LCX	CAG	Central Europe
Garg et al, 2000 [9]	0.95 (39 of 4,100)	Anomalous origin of RCA from LCS/NCS	CAG	India
Angelini et al, 2002 [10]	5.64 (110 of 1,950)	Split RCA	CAG	USA
Yildiz et al, 2010 [3]	0.90 (112 of 12,457)	Absent LM trunk with separate origin of LAD and LCX	CAG	Turkey
Erol et al, 2011 [11]	1.96 (53 of 2,096)	Absent LM trunk with separate origin of LAD and LCX/origin of RCA from LCS	MDCT	Turkey
Fujimoto et al, 2011 [12]	1.52 (89 of 5,869)	Anomalous origin of RCA from LCS	MDCT	Japan
Sivri et al, 2012 [35]	0.74 (95 of 12,814)	Anomalous origin of LCX from RCS/RCA	CAG	Turkey
Sohrabi et al, 2012 [27]	1.30 (79 of 6,065)	Absent LM trunk with separate origin of LAD and LCX	CAG	Iran
Xu et al, 2012 [36]	1.02 (124 of 12,415)	Anomalous origin of RCA from LCS	CTCA	China
Yuksel et al, 2013 [13]	0.29 (48 of 16,573)	Anomalous origin of LCX from RCS/RCA	CAG	Turkey
Namgung et al, 2014 [37]	1.16 (103 of 8,864)	Anomalous origin of RCA from LCS	MDCT	Korea
Tharwat et al, 2014 [23]	2.7 (115 of 4,246)	Anomalous origin of LCX from RCS/RCA	CAG	Egypt
Altin et al, 2015 [38]	1.4 (78 of 5,548)	Absent LM trunk with separate origin of LAD and LCX	CAG	Turkey
Sivakumar et al, 2017 [28]	2.06 (32 of 1,547)	Anomalous origin of RCA from LCS	CAG	India
Somashekhara, 2017 [24]	0.65 (162 of 25,023)	Anomalous origin of RCA from LCS	CAG	India
Nawale et al, 2018 [29]	1.91 (86 of 4,481)	Anomalous origin of RCA from LCS/NCS	CAG	India

Table 5. Incidence and Patterns of Coronary Anomalies in Previous Studies

Author/year of publication

Incidence (%)

Most common anomaly

Imaging modality

Country

LM: left main; LAD: left anterior descending artery; LCX: left circumflex artery; RCA: right coronary artery; RCS: right coronary sinus; LCS: left coronary sinus; NCS: non-coronary sinus; CAG: catheter coronary angiography; MDCT: multidetector computed tomography.

Yamanaka et al, 1990 [2]

1.30 (1,686 of 126,595)

Absent LM trunk with separate origin of LAD and LCX

CAG

USA

Kaku et al, 1996 [8]

0.31 (56 of 17,731)

Anomalous origin of RCA from LCS

CAG

Japan

Kardos et al, 1997 [7]

1.34 (103 of 7,694)

Absent LM trunk with separate origin of LAD and LCX

CAG

Central Europe

Garg et al, 2000 [9]

0.95 (39 of 4,100)

Anomalous origin of RCA from LCS/NCS

CAG

India

Angelini et al, 2002 [10]

5.64 (110 of 1,950)

Split RCA

CAG

USA

Yildiz et al, 2010 [3]

0.90 (112 of 12,457)

Absent LM trunk with separate origin of LAD and LCX

CAG

Turkey

Erol et al, 2011 [11]

1.96 (53 of 2,096)

Absent LM trunk with separate origin of LAD and LCX/origin of RCA from LCS

MDCT

Turkey

Fujimoto et al, 2011 [12]

1.52 (89 of 5,869)

Anomalous origin of RCA from LCS

MDCT

Japan

Sivri et al, 2012 [35]

0.74 (95 of 12,814)

Anomalous origin of LCX from RCS/RCA

CAG

Turkey

Sohrabi et al, 2012 [27]

1.30 (79 of 6,065)

Absent LM trunk with separate origin of LAD and LCX

CAG

Iran

Xu et al, 2012 [36]

1.02 (124 of 12,415)

Anomalous origin of RCA from LCS

CTCA

China

Yuksel et al, 2013 [13]

0.29 (48 of 16,573)

Anomalous origin of LCX from RCS/RCA

CAG

Turkey

Namgung et al, 2014 [37]

1.16 (103 of 8,864)

Anomalous origin of RCA from LCS

MDCT

Korea

Tharwat et al, 2014 [23]

2.7 (115 of 4,246)

Anomalous origin of LCX from RCS/RCA

CAG

Egypt

Altin et al, 2015 [38]

1.4 (78 of 5,548)

Absent LM trunk with separate origin of LAD and LCX

CAG

Turkey

Sivakumar et al, 2017 [28]

2.06 (32 of 1,547)

Anomalous origin of RCA from LCS

CAG

India

Somashekhara, 2017 [24]

0.65 (162 of 25,023)

Anomalous origin of RCA from LCS

CAG

India

Nawale et al, 2018 [29]

1.91 (86 of 4,481)

Anomalous origin of RCA from LCS/NCS

CAG

India