Corresponding Author
Key words: computed tomography, coronary angiography, coronary vessel anomaly
While the true prevalence of coronary artery with anomalous aortic origin is uncertain, literature estimates ranged from 0.1% to 1.0% of the general population.1 It is an important differential diagnosis to be considered when a coronary artery is not seen at the expected territory during coronary angiography. Coronary computed tomographic angiography (CCTA) or cardiovascular magnetic resonance angiography can help delineate the course of an anomalous coronary artery and its relationship with adjacent structures.2 The management plan is controversial given the scarcity of good-quality data.
In this issue of JACC: Case Reports, Elbasha et al3 reported an extremely rare case of anomalous right coronary artery (RCA) originating from the mid-segment of left anterior descending artery (LAD) with an interarterial course between aorta and pulmonary arteries. The case was initially mistaken as an ostial RCA chronic total occlusion (CTO) with retrograde from LAD. Careful review of the angiogram and CCTA confirmed the diagnosis of anomalous RCA arising from mid-LAD. Further functional assessment with cardiovascular magnetic resonance and stress echocardiography were both negative. A decision of conservative management was made.
This case highlighted the importance of preoperative planning for CTO intervention. In different CTO crossing algorithms,4 careful analysis of CCTA is often incorporated for delineation of anatomy and procedural planning. Preprocedural planning with CCTA might improve success rate and reduce perforation risk.5 When coronary angiography demonstrates typical CTO morphology with low complexity, experienced operators can safely proceed with high success rates. In this particular case, however, CCTA confirmed the anomalous course of RCA and saved the patient from unnecessary intervention. Should the case proceed with ad hoc coronary intervention, it might result in devastating complications such as perforation of coronary artery and injury of aortic root.
Given the rarity of the anomaly, there is a lack of good-quality evidence to guide optimal management. The latest American College of Cardiology guideline for adult congenital heart disease in 2025 suggested computed tomography or magnetic resonance imaging to confirm the anatomy and functional assessment for any ischemia to guide management.2 For patients with RCA arising from left sinus and without evidence of ischemia, either continued observation or surgery may be reasonable according to the guideline. The risk of sudden cardiac death for anomaly with an interarterial course is controversial.6 There is a case report of percutaneous intervention by stenting the interarterial segment, but evidence is otherwise limited.7 Surgical options such as unroofing and transposition are associated with significant operative risk too. Management plan requires shared decision-making by both physician and patient with the aim to balance risk and benefit in the long term. In this case, conservative management is reasonable and in line with guideline recommendation given different modalities of functional studies showed no inducible ischemia.
In summary, CCTA is valuable to delineate the course of the coronary artery with an anomalous aortic origin, and functional study helps to guide management plan. Meticulous planning prior to CTO intervention is crucial for less-experienced operators, especially in complex or ambiguous coronary anatomy.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
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References
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