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Anatomy Atlases: Illustrated Encyclopedia of Human Anatomic Variation: Opus II: Cardiovascular System: Arteries: Head, Neck, and Thorax: Coronary Arteries

Illustrated Encyclopedia of Human Anatomic Variation: Opus II: Cardiovascular System: Arteries: Head, Neck, and Thorax

Coronary Arteries

Ronald A. Bergman, PhD
Adel K. Afifi, MD, MS
Ryosuke Miyauchi, MD

Peer Review Status: Internally Peer Reviewed


A TV star sued his cardiac surgeon because, in a by-pass operation, he negligently removed the healthy coronary artery leaving the defective one behind. The surgeon was an experienced cardiac surgeon. The attorney for the surgeon argued in court that the mix-up was a natural result of "abnormalities in the patient's heart". The lawyers put the patient's arteries on trial. Their defense was that the patient had "freakish anatomy". The case was settled out of court in favor of the patient. Information source: People (Weekly). 612/00. Variations of the coronary arteries are numerous, well known and are easily accessed.

Branches of the coronary arteries may vary in origin, distribution, number, and size. The left coronary artery is more variable than the right. The branches may arise as a common trunk, or both arise from the same aortic sinus. The anterior interventricular and terminal branches of the left coronary sometimes arise separately from the aortic sinus. In some cases, a single coronary artery serves the entire heart; either the right or the left coronary artery is absent. One coronary artery may be larger than usual and the other correspondingly smaller. Very rarely, an extra coronary artery arises from the pulmonary artery. Occasionally, there are two interventricular branches, or two or more posterior interventricular branches. There may be three or even four independent coronary arteries which are, generally, quite small. A conus artery arising from the aorta was found in 50% of 651 subjects. Coronary artery preponderance occurs in about 30% of cases; left coronary is preponderant in 12% of cases and the right coronary in about 18%. Left coronary artery dominance is eight times more frequent in males (18.2%) than in females (2.6%), while right coronary artery preponderance is almost twice as common in females (23.1%) as in males (14.6%).In some unusual circumstances, the left coronary circumflex branch may be the dominant artery. The right and left coronary arteries may arise from a common trunk (Brenner, et.al.).

The right coronary artery occasionally arises from the pulmonary trunk, usually without adverse consequences. Cases have also been reported of the left coronary arising from the pulmonary trunk, but this is usually associated with myocardial ischemia, with patients dying at 13 months or younger. In one case, however, a female patient survived 60 years; in another case, a male survived 34 years (cause of death unrelated to heart disease). In 14,000 consecutive autopsies, this condition was found three times. When both coronary arteries arise from the pulmonary trunk, death occurs shortly after birth.

It has been reported that in 50% of hearts, the sinoatrial and atrioventricular nodes were supplied by the right coronary, and in 7% of hearts, these nodes were supplied by the left coronary. In the remainder (43%), one artery supplied one node and the other artery supplied the other, in either combination. Spalteholz, however, reported the sinoatrial node to be supplied in 68% of cases by the right coronary, in about 32% by the left coronary, and very rarely by an extracardiac artery.

The left coronary circumflex branch may be larger and longer than usual, giving off the posterior interventricular artery before anastomosing with a smaller right coronary artery on the posterior surface of the heart. Mavi, et al reported that from among 10,042 adult Turkish patients only 27 (0.3%) had variations in the origin of the left circumflex coronary (LCC) artery. The LCC arose from the left coronary sinus of Valsalva in 15 (55.5% of the total of 27 patients), from the right coronary sinus of Valsalva in 7 (25.9%) patients, and from the proximal part of the right coronary artery in 8 (29.6%) patients. Lack of knowledge of these variations may have dire consequences in catheterization, valve replacement, or bypass surgery.

The Incidence of Variations of the Left Circumflex Coronary Artery (CCA) Found at Coronary Angiography or from Autopsy Studies
Author # of Patients Incidence Type (see below) Population
By Angiography:
Cieslinski et al 4016 26 (0.6%) A12,B2,C12 German
Garg et al 4100 14 (0.3%) B12,C2 India
Kaku et al 17731 7 (0%) B7 Japan
Kardos et al 7694 83 (1.1%) A54,B C29 Central European
Mavi et al 10042 27 (0.3%) A12,B7,C8 Turkish
Topaz et al 13010 22 (0.2%) B9,C13 Hispanic
Yamanaka &
Hobb
126595 984 (0.8%) A513,BC467,D4 American
By Autopsy:
Frescura, et al   0.2%   Italian
Kurjia, et al   0.8%   Iraqi
  1. Number of circumflex coronary artery (CCA) originating from left sinus of Valsalva
  2. Number of CCA originating from right sinus of Valsalva
  3. Number of CCA originating from right coronary artery
  4. Number of absent CCA.


Modified from Mavi et al., Saudi Med. J., vol. 23(11):1390-1393, 2002.

An infrequent branch of the right coronary is a septal branch that supplies the middle part of the septum and both limbs of the conduction system.

Occasionally, a coronary artery arises from the common carotid, later giving rise to right and left branches. "Large and direct" anastomoses between the right and left coronary arteries have been reported in 9% of individuals. Smaller anastomoses between the two vessels occur in most hearts. The absence of right/left coronary anastomoses was said to occur in 3% of hearts.

The anterior interventricular (descending) coronary artery and vein have been reported to arise from the left internal thoracic (mammary) artery and vein (Robicsek, et al.).

Coronary Artery Anomalies Found in Angiographic Studies

Author

No. Patients

Variations

Incidence

Baltaxe

1000

9

0.9%.

Chaitman

3750

31

0.83%.

Donaldson

9153

82

0.9%.

Engle

4250

51

1.2%.

Hobbs

38703

601

1.55%.

Kimbiris

7000

45

0.64%.

Liberthson

?

21

0.6%.

Wilkins

10661

83

0.78%.

Yamanaka

126595

1686

1.3%.

The incidence of congenital coronary artery anomalies, in angiographic studies is about 1.3%, based on 126,595 cases where 1,686 were found (Yamanaka and Hobbs). These authors classified coronary artery variations as 1) benign and 2) potentially serious. The classification follows:

1) BENIGN CORONARY ANOMALIES

a) Separate origin of left anterior descending artery and left circumflex from the left sinus Valsalva (513 cases, 0.41% incidence, 30.4% of all anomalies).

b) Absent left circumflex (with maximally dominant right coronary artery) (4 cases, 0.003% incidence, 0.24% of all anomalies).

c) Origin of left circumflex from right coronary or right sinus of Valsalva (467 cases, 0.37% incidence, 27.7% of all anomalies).

d) Ectopic origin of right coronary artery or left main trunk from posterior sinus of Valsalva (Left main trunk; 16 cases, 0.0008% incidence, 0.95% of all anomalies. Right coronary; 4 cases, 0.003%, 0.24% of all anomalies).

e) Ectopic coronary origin from the ascending aorta (Left main trunk; 16 cases, 0.013% incidence, 0.95% of all anomalies. Right coronary; 188 cases, 0.15% incidence, 11.2% of all anomalies).

f) Intercoronary communication (3 cases, 0.002% incidence, 0.18% of all anomalies).

g) Small coronary artery fistulae (163 cases, 0.12% incidence, 9.7% of all anomalies). Total No. Anomalies...1359, Incidence...1.07%, Of all anomalies...80.6%.

2) POTENTIALLY SERIOUS CORONARY ANOMALIES

a) Ectopic coronary origin from the pulmonary artery (Bland-White-Garland syndrome) (Left main trunk from pulmonary; 10 cases, 0.008 % incidence, 0.59% of all anomalies).

Left anterior descending; 1 case, 0.0008% incidence, 0.06% of all anomalies.

Right coronary artery from pulmonary artery; 2 cases, 0.002% incidence, 0.12% of all anomalies).

b) Ectopic origin of the left coronary artery from the right sinus of Valsalva Left main trunk from right sinus of Valsalva; 22 cases, 0.017 % incidence, 1.3% of all anomalies.

Left anterior descending from right sinus of Valsalva; 38 cases, 0.03% incidence, 2.3% of all anomalies.

Right coronary artery from left sinus of Valsalva; 136 cases, 0.107% incidence, 8.1% of all anomalies.

Note: Shirani and Roberts reported four cases of the ectopic origin of the left main coronary artery from the right aortic sinus with a retroaortic course. In none of the four patients did the unusual origin and course of the left coronary artery factor in causing their death (32, 45, 57, and 69 years of age). These same authors reported that anomalous origin of the left circumflex coronary from the right aortic sinus or from the right coronary artery with a retroaortic course is the most common congenital coronary artery anomaly; it occurs in about one in three hundred human hearts or 0.33%. The discovery of coronary artery variations in patients undergoing coronary angiography is about 1%.

c). Ectopic origin of right coronary artery from the left sinus of Valsalva (data, see above).

d). Single coronary artery.

The level of the orifices of the coronary arteries in the sinuses of Valaslva varies in both the vertical and horizontal directions. Commonly they lie at the level of the free edge of the cusp, but they are often above this level and in some cases below. While most commonly at the center of the sinus they are often found nearer their anterior margin. Two coronary arteries have been found to arise from a common trunk or both to arise from one sinus of Valsalva. Frequently the number of coronary arteries are increased to three or four. These supplementary vessels are generally small. Symmers (1907) reported the following;

In 100 Hearts

1 right accessory coronary artery

26

2 right accessory coronary arteries

9

3 right accessory coronary arteries

2

4 right accessory coronary arteries

1

1 left accessory coronary artery

1

Total

39

These arteries arise from the aorta near the main coronary trunk. They occur on both sides but more frequently on the right. In rare instances, an additional coronary artery may arise from the pulmonary trunk.

Note: "Pistol" Pete Maravich ran the basketball courts in high school, college, and was an NBA professional for a total of 30 years despite having a congenitally absent left coronary artery. Reported in Cardiovascular News, pp. 16-19, April, 1988.

It has been found that when variations of the coronary arteries occur, and these are infrequent, they are most commonly associated with the left coronary artery.

According to Vieweg, Alpert and Hagan the sinoatrial node artery arose from the right coronary artery in 53%, the left coronary artery in 35%, and from both in 11% of 118 patients. The artrioventricular node artery arose from the right coronary in 84%, the left coronary in 8%, and from both in 8% of the same 118 patients with normal coronary arteriograms.

Variations in Origin of Coronary Arteries with Relationship to the Aorta in 4,250 patients undergoing Coronary Arteriography.
From Engel, Torres and Page, 1975.

Origin

Number of Patients

Course of Ectopic Artery in relationship to the aorta

RCA from LSV

3

Anterior

LAD and CX separate from LSV

8

---

CX from RSV or RCA

30

Posterior

LAD from RSV

3

Anterior

LAD and CX from RSV (separate ostia)

4

CX posterior, LAD anterior

MLCA from RSV

1

Anterior

MLCA from PA

1

---

LAD from PA (CX from RSV)

1

CX posterior

RCA = right coronary artery; LSV = left sinus of Valsalva; LAD = left anterior descending; CX =circumflex; RSV = right sinus of Valsalva; MLCA= main left coronary artery; PA = pulmonary artery.

The unusual origin of either the left main coronary artery (LMCA) or right coronary artery (RCA) from the aorta with subsequent coursing between the aorta and pulmonary trunk is rare - and may lead to a clinically important outcome.

Image 12, Image 91, Image 147A, Image 147B, Image 196, Image 271, Image 273

Circumflex:

See Image 12

Left Coronary:

Image 155, Image 259A, Image 259B, Image 259C, Image 259D, Image 259E

Left Anterior Descending:

See Image 12

Origin of:

Image 223, Image 438

Preponderance:

See Image 91, See Image 259A-E, Image 274, Image 275

Right Coronary:

Image 135, See 259A-E

Replacing:

Image 397

Single:

See Image 397, Image 409, Image 432


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