Presentation
Atypical angina. History of hypertension. Coronary angiogram in the past. Unknown history of coronary artery disease.
Patient Data
Technique
patient premedication: beta blocker and nitrates
acquisition method: step and shoot (prospective acquisition)
contrast injection protocol: triphasic injection
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image reconstruction:
standard with and without edge correction
dual-energy maps (see next study)
Findings
anomalous origin of the left main stem from right coronary sinus with a prepulmonic course
right coronary arterial dominance with a large right posterolateral branch (PLB)
corkscrew-like tortuous terminal vessels
Plaque burden:
calcium score: ~120
segment involvement score (SIS): 4 segments
gives off the posterior descending artery (PDA) and a large posterolateral branch (PLB)
calcified plaques with mild stenosis in the proximal segment (D: 25-49%; A: <60-65%)
no plaques or stenoses in the middle segment, PDA and RPLB
Left main (LM): anomalous origin from the right coronary sinus, prepulmonic course
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calcified plaques with mild stenosis (D: 25-49%; A: <50%)
Left anterior descending artery (LAD): thin short
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no plaques or stenoses
Ramus intermedius: strong, branching, supplying the anterior wall
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no plaques or stenoses
Circumflex artery (CX): one thin obtuse marginal branch (OM)
proximal non-stenotic plaque with high-risk features (spotty calcium & positive remodeling)
no further plaques or stenoses in the main epicardial vessel and the marginal branch
Impression
anomalous origin of the left main stem from right coronary sinus with a prepulmonic course
right coronary arterial dominance maybe even superdominant right coronary artery
mild amount of plaque - CAC-DRS A2/N3 and V2/N3
mild non-obstructive coronary artery disease - CADRADS2/P2/HRP/E
Exam courtesy: Yvonne Kirchner-Bock (radiographer)
Virtual non-contrast
virtual non-contrast (VNC) images can be used as a substitute for a non-contrast scan and to depict coronary calcifications
window setting ranging from -200 to 400 (C:100 W:600)
Iodine no water + virtual non-contrast overlay
iodine no water images obtained by subtracting water from contrast-enhanced images with a color-coded virtual non-contrast overlay (VNC) ranging from -200 to 400 (C:100 W:600)
this setting can be also used to illustrate coronary calcium, the punctate calcifications of the proximal circumflex artery plaque are also barely visible
MonoE 40
virtual monoenergetic or monochromatic images synthesized at a level of 40 keV
reconstructions with a window setting C:800 W:2000
Conventional + MonoE 40 overlay
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conventional images, reconstructed with a standard soft tissue filter and augmented with a color-coded MonoE 40 overlay ranging from -600 to 1400 (C:400 W:2000)
Z-effective
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the effective atomic number Zeff calculated by dual-energy analysis
Case Discussion
An anomalous origin of the left main coronary artery from the right coronary sinus is a very rare coronary anomaly, which in this case is characterized by two adjacent ostia and a precardiac or prepulmonic course of the left main stem, namely anterior to the pulmonary outflow tract 1-3.
In contrast to an interarterial course, which is considered malignant, especially if intramural, the prepulmonic course is considered benign 1-3. There is also right coronary arterial dominance with a superdominant right coronary artery characterized by a large right posterolateral branch supplying the inferolateral wall of the left ventricle, which is apparently not so uncommon in this setting 4-6.
When I spoke to this patient after the examination, she told me that she had a cardiac catheterization long ago and the cardiologist told her afterwards that "she was a very special person due to a rare coronary variant".
For her non-obstructive coronary artery disease, we recommended risk factor modification and preventive therapy. With regard to the high-risk plaque, a more aggressive approach can be considered.
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