Unusual Coronary Anatomical Anomaly: Common Origin for All Three Major Coronary Arteries Arising from the Right Coronary Sinus

Coronary artery anomalies that are discovered during angiography may help govern subsequent treatment options. We report the unusual angiographic findings of an 81-year-old woman presenting with increasing exertional angina. Coronary angiography was performed via the right femoral route. This demonstrated small-caliber vessels emanating from what was at first thought to be a conventional left main stem artery (Figure 1). The right coronary artery could not be intubated at the time due to significant unfolding of the aorta, and a follow-up procedure was arranged. Repeat angiography was performed via the right radial artery (Figure 2), revealing a common origin in the right coronary sinus for the right coronary (A), circumflex (B) and left anterior descending (C) arteries. The left anterior descending artery had a moderately severe stenosis mid-section with further disease distally (Figure 3, D), the circumflex artery had a tight ostial stenosis (E) and the right coronary artery had tight disease in its mid-course (F). Left ventriculography revealed well preserved systolic function. Despite her triple-vessel disease, the patient did not want to undergo intervention and was optimized on anti-anginal therapy. A consensus was reached to only intervene if her symptoms worsened despite medication. She currently remains well. The most common coronary artery anomaly is an aberrant origin of the left main or right coronary artery from the opposite sinus of Valsalva. There have been few reported cases of dual anomalies where the right coronary artery arises from the left sinus, and the left coronary artery arises from the posterior sinus. There is, however, little documented on patients with a common origin for all three major coronaries, and our treatment options remain governed by symptoms, prognostic benefit versus risk of intervention and patient selection. From the NHS, Department of Cardiology, Watford General Hospital, Watford, United Kingdom. The authors report no conflicts of interest regarding the content herein. Manuscript submitted July 7, 2009, provisional acceptance given July 20, 2009, final version accepted July 27, 2009. Address for correspondence: Nikunj R. Shah, MBBS, MRCP, 19, Ashleigh Court, Sherwood, Preston, Lancashire, United Kingdom PR2 9WU. E-mail: nikunjravshah@hotmail.com