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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 4  |  Page : 108-111

Case of Double Right Coronary Artery: Diagnosed on Computed Tomography Coronary Angiography


Department of Radiology, Lokmanya Tilak Municipal Government Hospital and Medical College, Sion, Mumbai, Maharashtra, India

Date of Web Publication21-Dec-2015

Correspondence Address:
Narayan Solanki
Department of Radiology, Lokmanya Tilak Municipal Government Hospital and Medical College, Sion - 400 022, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-449X.168469

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  Abstract 

Anomalies of the coronary artery are often asymptomatic and uncommon. Double right coronary artery (RCA) is a very rare coronary anomaly. So far, the number of reported cases of double RCA is not many. Nevertheless, there have been several reports of double RCA in the literature, particularly in the last decade. We aim to present a similar case. Multidetector computed tomography (CT) is becoming an alternative method for the diagnosis of coronary artery anomalies. We present the multidetector coronary CT angiography findings from a patient with RCA duplication. Two right coronary arteries originating from two separate ostia of the right aortic sinus were observed.

Keywords: Catheter angiography, computed tomography coronary angiography, double right coronary artery


How to cite this article:
Joshi A, Solanki N, Bhuta M, Bava JS. Case of Double Right Coronary Artery: Diagnosed on Computed Tomography Coronary Angiography. Heart India 2015;3:108-11

How to cite this URL:
Joshi A, Solanki N, Bhuta M, Bava JS. Case of Double Right Coronary Artery: Diagnosed on Computed Tomography Coronary Angiography. Heart India [serial online] 2015 [cited 2020 Jul 15];3:108-11. Available from: http://www.heartindia.net/text.asp?2015/3/4/108/168469


  Introduction Top


Coronary artery anomalies are usually, incidentally diagnosed at the time of coronary angiography, digital subtraction angiography, computed tomographic angiography (CTA), or autopsy. Anomalies of the coronary artery are often asymptomatic and uncommon. Double right coronary artery (RCA) is a very rare coronary anomaly. Although considered benign and hemodynamically insignificant, it might be complicated with atherosclerosis and present with the symptomatology of atherosclerosis. In conclusion, although controversy exists about the definition of double RCA and generally considered as a benign entity, it might be atherosclerotic and can cause acute coronary syndromes including myocardial infarction and be associated with other anomalies. Although coronary angiography is the most widely used diagnostic modality, multidetector computed tomography (CT) is fast rising as another promising diagnostic modality as the conventional technique has few limitations.


  Case Report Top


A 28-year-old man presented with the complaints of occasional episodes of left sided chest pain, especially on after exertion. He was a nondiabetic and a nonhypertensive. The physical examination was completely normal. Cardiac enzymes and troponin-T were also found to be normal. Electrocardiogram was also normal. No abnormality was detected on coronary angiography [Figure 1] and [Figure 2]. For further evaluation, a CT coronary angiography was advised.
Figure 1: Catheter angiography-right coronary artery (thick blue arrow), tip of catheter (blue arrow head), right marginal artery (notched blue arrow), and posterior descending artery (thin blue arrow)

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Figure 2: Catheter angiography-right coronary artery (thick blue arrow), tip of catheter (blue arrow head), and right marginal artery (notched blue arrow), and posterior descending artery with interventricular branches (thin blue arrow)

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The CT coronary angiography was performed on a 128 slice CT scanner after injecting 100 ml of nonionic iodinated contrast, followed by a saline chase. The CT revealed:

  • Normal origin, course, and caliber of the left main artery, the left circumflex artery, and the left anterior descending arteries.
  • Two right coronary arteries were seen arising from two separate ostia from the right coronary sinus [Figure 3], [Figure 4], [Figure 5] and [Figure 8]. Anteriorly arising artery was seen further continuing as the acute marginal artery and was thinner in caliber. However, both the arteries were well opacified with no atherosclerotic or athero calcific plaque.
    Figure 3: Axial section coronary CT-right coronary artery (thin blue arrow), another vessel (thick blue arrow) arising from anterior coronary sinus (notched blue arrow) anterior to the origin of right coronary artery

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    Figure 4: Oblique-axial section coronary CT-right coronary artery (thin blue arrow), another vessel i.e. second right coronary artery (thick blue arrow) arising from anterior coronary sinus (notched blue arrow) anterior to the origin of right coronary artery

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    Figure 5: Axial section coronary CT-origin of right coronary artery (thick blue arrow) and origin of another vessel i.e. second right coronary artery (thin blue arrow) arising from anterior coronary sinus (notched blue arrow) anterior to the origin of right coronary artery

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  Discussion Top


Coronary anomalies are incidentally detected during coronary angiography (conventional-CTA). Congenital coronary artery anomalies are not common, found only in ~1% (range 0.1-2%) of patients. [1],[2] Until now, double RCA was defined as double, duplicated, dual, or split and reported 39 times and detected in 46 patients in the literature in which more than the half of the cases were reported from Turkey. [3] Most of these patients had double RCA originated from the single ostium. However, 18 of them had double RCA, with separate ostia located in close proximity, in the right coronary sinus. One of the double RCAs has a sinoatrial branch and terminates as a posterior descending artery. The other one has a conal and right ventricular branches and ends as an acute marginal branch.

Since the first report, this rare anomaly has been accepted as a benign entity. Although the double RCA is generally considered as a benign entity, it might be atherosclerotic and can cause acute coronary syndromes including myocardial infarction, sudden death, and be associated with other anomalies. [4],[5],[6] In the absence of atherosclerotic stenosis, ischemia can be a result of anatomical malformations, including an acute branching by an anomalous vessel, myocardial squeezing, vasospasm, and a small artery. [7] In most of the cases, the first symptom at admission is chest pain. It is predominantly seen in males and might origin from either single or separate ostia. In our case, it was not diagnosed initially on conventional invasive catheter angiography [Figure 1] and [Figure 2]; as such cases can be easily missed by traditionally procedure method. However, by using Judkins technique from the right femoral artery, the RCA can be selectively cannulated with a 6 Fr Judkins right diagnostic catheter. Additional injection of contrast above the ascending aorta site while slowly pulling back the catheter during selective coronary angiography; double RCA, each having its own ostium, can be seen arising separately from the right aortic sinus. To diagnose a split RCA by angiography, further evaluation, such as aortography, may be helpful.

The incidence of stenotic coronary lesions is more prevalent, especially in cases with single than the separate ostia and the prevalence of atherosclerotic coronary artery disease are higher. Previously reported cases of double RCA presented with acute inferior myocardial infarction, [6],[8],[9] most of them had a single ostium. Currently, there is no study documenting any predisposition to acute coronary syndromes in cases with a single ostium. The cases with double ostia seem to be benign, and the increased risk of atherosclerosis in these patients still remains controversial.

In recent papers, multidetector-row computed tomography (MDCT) was offered as an alternative or adjunctive imaging method. MDCT allows three-dimensional comprehension of the coronary artery system, and it is extremely useful to identify the congenital coronary anomalies such as the anomalous origin of the RCA [eg. [Figure 6] and [Figure 7] of our case]. MDCT might also be useful to differentiate double RCA from high take off of a large branch. [10] In conclusion, although double RCA is a rare anomaly, every operator should be familiar with it in order to perform an adequate examination.
Figure 6: 3D reconstruction of coronary CT-right coronary artery (thick blue arrow) and another vessel i.e. second right coronary artery (thin blue arrow) arising from anterior coronary sinus (notched blue arrow) anterior to the origin of right coronary artery, aorta (arrowhead).

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Figure 7: 3D reconstruction of coronary CT-right coronary artery (thick blue arrow) and another vessel i.e. second right coronary artery (thin blue arrow) arising from anterior coronary sinus (notched blue arrow) anterior to the origin of right coronary artery, aorta (arrowhead)

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Figure 8: Axial section coronary CT (inverted format)-origin of right coronary artery (thick blue arrow) and origin of another vessel i.e. second right coronary artery (thin blue arrow) arising from anterior coronary sinus (notched blue arrow) anterior to the origin of right coronary artery

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  Conclusion Top


Double RCA is a rare congenital coronary anomaly with a potential of atherosclerotic coronary artery disease and acute coronary syndromes in cases with the duplicated RCA arising from a single ostium. Because of this reason, any coronary intervention in these patients can lead to unexpected complications. Hence, the comprehensive diagnosis and the knowledge of this variant is important. Thus, while analyzing CT coronary angiographies, a keen eye is essential to look for the anatomical variations of the coronary circulation, even when such anomalies are not mentioned in the corresponding conventional angiographies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Datta J, White CS, Gilkeson RC, Meyer CA, Kansal S, Jani ML, et al. Anomalous coronary arteries in adults: Depiction at multi-detector row CT angiography. Radiology 2005;235:812-8.  Back to cited text no. 1
    
2.
Pelliccia A. Congenital coronary artery anomalies in young patients: New perspectives for timely identification. J Am Coll Cardiol 2001;37:598-600.  Back to cited text no. 2
    
3.
Chien TM, Chen CW, Chen HM, Lee CS, Lin CC, Chen YF. Double right coronary artery and its clinical implications. Cardiol Young 2014;24:5-12.  Back to cited text no. 3
    
4.
Timurkaynak T, Ciftci H, Cengel A. Double right coronary artery with atherosclerosis: A rare coronary artery anomaly. J Invasive Cardiol 2002;14:337-9.  Back to cited text no. 4
    
5.
Ozeren A, Aydin M, Bilge M, Dursun A, Onuk T. Atherosclerotic double right coronary artery and ectasia of left coronary arteries in a patient with presented acute coronary syndrome and ventricular tachycardia. Int J Cardiol 2005;102:341-3.  Back to cited text no. 5
    
6.
Rohit M, Bagga S, Talwar KK. Double right coronary artery with acute inferior wall myocardial infarction. J Invasive Cardiol 2008;20:E37-40.  Back to cited text no. 6
    
7.
Tuncer C, Batyraliev T, Yilmaz R, Gokce M, Eryonucu B, Koroglu S. Origin and distribution anomalies of the left anterior descending artery in 70,850 adult patients: Multicenter data collection. Catheter Cardiovasc Interv 2006;68:574-85.  Back to cited text no. 7
    
8.
Akcay A, Koroglu S, Kaya H, Koleoglu M, Acar G. An unusual appearance of double right coronary artery. Cardiol Res Pract 2010;2010. pii: 123846.  Back to cited text no. 8
    
9.
Acet H, Ozyurtlu F, Bilik MZ, Ertas F. A rare coronary anomaly: Atypical double right coronary artery with an acute inferior myocardial infarction. Korean Circ J 2012;42:208-11.  Back to cited text no. 9
    
10.
Kunimasa T, Sato Y, Ichikawa M, Ito S, Takagi T, Lee T, et al. MDCT detection of double right coronary artery arising from a single ostium in the right sinus of Valsalva: Report of 2 cases. Int J Cardiol 2007;115:239-41.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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