9/30/2018 The Radiology Assistant : Coronary anatomy and anomalies

Coronary anatomy and anomalies

Robin Smithuis and Tineke Willems
Radiology department of the Rijnland Hospital Leiderdorp and the University Medical Centre
Groningen, the Netherlands.

Publicationdate October 14, 2008

In this article we describe the anatomy of the

coronary arteries of the heart and some of the
anomalies with illustrations and CT-images.
This article is an update of an article that
appeared earlier in the Radiology Assistant.

by Robin Smithuis and Tineke Wilems

Radiology department of the Rijnland Hospital
Leiderdorp and the University Medical Centre
Groningen, the Netherlands.

Overview

On the left an overview of the coronary arteries

in the anterior projection.

Left Main or left coronary artery (LCA)

Left anterior descending (LAD)
diagonal branches (D1, D2)
septal branches
Circumflex (Cx)
Marginal branches (M1,M2)
Right coronary artery
Acute marginal branch (AM)
AV node branch
Posterior descending artery (PDA)

RCA, LAD and Cx in the anterior projection

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On the left an overview of the coronary arteries

in the right anterior oblique projection.

Left Main or left coronary artery (LCA)

Left anterior descending (LAD)
diagonal branches (D1, D2)
septal branches
Circumflex (Cx)
Marginal branches (M1,M2)
Right coronary artery
Acute marginal branch (AM)
AV node branch
Posterior descending artery (PDA)

RCA, LAD and Cx in the right anterior oblique

projection

On the left an overview of the coronary arteries

in the lateral projection.

Left Main or left coronary artery (LCA)

Left anterior descending (LAD)
diagonal branches (D1, D2)
septal branches
Circumflex (Cx)
Marginal branches (M1,M2)
Right coronary artery
Acute marginal branch (AM)
AV node branch
Posterior descending artery (PDA)

RCA, LAD and Cx in the lateral projection

Read more about coronary anatomy
inIntroduction to cardiothoracic imaging

Left Coronary Artery (LCA)

The left coronary artery (LCA) is also known as

the left main.
The LCA arises from the left coronary cusp.

The aortic valve has three leaflets, each having

a cusp or cup-like configuration.
These are known as the left coronary cusp (L),
the right coronary cusp (R) and the posterior
non-coronary cusp (N).
Just above the aortic valves there are anatomic
dilations of the ascending aorta, also known as
the sinus of Valsalva. The left aortic sinus gives
Left coronary (LC), right coronary (RC) and posterior
non-coronary (NC) cusp
rise to the left coronary artery.
The right aortic sinus which lies anteriorly,
gives rise to the right coronary artery.
The non-coronary sinus is postioned on the
right side.

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The LCA divides almost immediately into the

circumflex artery (Cx) and left anterior
descending artery (LAD).
On the left an axial CT-image.
The LCA travels between the right ventricle
outflow tract anteriorly and the left atrium
posteriorly and divides into LAD and Cx.

LCA divides into LAD and Cx

On the image on the left we see the left main

artery dividing into

Cx with obtuse marginal branch (OM)

LAD with diagonal branches (DB)

On volume rendered images the left atrial

appendage needs to be removed to get a good
look on the LCA.

In 15% of cases a third branch arises in

between the LAD and the Cx, known as the
ramus intermedius or intermediate branch.
This intermediate branche behaves as a
diagonal branch of the Cx.

Left Anterior Descending (LAD)

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The LAD travels in the anterior interventricular

groove and continues up to the apex of the
heart.
The LAD supplies the anterior part of the
septum with septal branches and the anterior
wall of the left ventricle with diagonal branches.
The LAD supplies most of the left ventricle and
also the AV-bundle.

Mnemonic: Diagonal branches arise from the

LAD.

CT image of the LAD in RAO projection

The diagonal branches come off the LAD and

run laterally to supply the antero-lateral wall of
the left ventricle.
The first diagonal branch serves as the
boundary between the proximal and mid portion
of the LAD (2).
There can be one or more diagonal branches:
D1, D2 , etc.

Circumflex (Cx)

The Cx lies in the left AV groove between the

left atrium and left ventricle and supplies the
vessels of the lateral wall of the left ventricle.
These vessels are known as obtuse marginals
(M1, M2...), because they supply the lateral
margin of the left ventricle and branch off with
an obtuse angle.
In most cases the Cx ends as an obtuse
marginal branch, but 10% of patients have a
left dominant circulation in which the Cx also
supplies the posterior descending artery (PDA).

Mnemonic: Marginal branches arise from the Cx

and supply the lateral Margin of the left
Circumflex and LAD seen in Lateral projection
ventricle.

Right Coronary Artery (RCA)

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RCA, LAD and LCx in Anterior projection
LEFT: RCA comes off the right sinus of
ValsalvaRIGHT: Conus artery comes off directly from
the aorta
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The Radiology Assistant : Coronary anatomy and anomalies
The right coronary artery arises from the
anterior sinus of Valsalva and courses through
the right atrioventricular (AV) groove between
the right artium and right ventricle to the
inferior part of the septum.
In 50-60% the first branch of the RCA is the
small conus branch, that supplies the right
ventricle outflow tract.
In 20-30% the conus branch arises directly
from the aorta.
In 60% a sinus node artery arises as second
branch of the RCA, that runs posteriorly to the
SA-node (in 40% it originates from the Cx).
The next branches are some diagonals that run
anteriorly to supply the anterior wall of the right
ventricle.
The large acute marginal branch (AM) comes off
with an acute angle and runs along the margin
of the right ventricle above the diaphragm.
The RCA continues in the AV groove posteriorly
and gives off a branch to the AV node.
In 65% of cases the posterior descending artery
(PDA) is a branch of the RCA (right dominant
circulation).
The PDA supplies the inferior wall of the left
ventricle and inferior part of the septum.
On the image on the far left we see the most
common situation, in which the RCA comes off
the right cusp and will provide the conus branch
at a lower level (not shown).
On the image next to it, we see a conus branch,
that comes off directly from the aorta.
The large acute marginal branch (AM) supplies
the lateral wall of the right ventricle.
In this case there is a right dominant
circulation, because the posterior descending
artery (PDA) comes off the RCA.
Coronary Anomalies
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Coronary anomalies are uncommon with a

prevalence of 1%.
Early detection and evaluation of coronary
artery anomalies is essential because of their
potential association with myocardial ischemia
and sudden death (3).
With the increased use of cardiac-CT, we will
see these anomalies more frequently.

Coronary anomalies can be differentiated into

anomalies of the origin, the course and
termination (Table).

The illustration in the left upper corner is the

most common and clinically significant
anomaly.
There is an anomalous origin of the LCA from
the right sinus of Valsalva and the LCA courses
between the aorta and pulmonary artery.
This interarterial course can lead to
compression of the LCA (yellow arrows)
resulting in myocardial ischemia.

The other anomalies in the figure on the left are

not hemodynamically significant.

Interarterial LCA

On the left images of a patient with an

anomalous origin of the LCA from the right
sinus of Valsalva and coursing between the
aorta and pulmonary artery.
Sudden death is frequently observed in these
patients.

ALCAPA

On the left images of a patient with an

anomalous origin of the LCA from the
pulmonary artery, also known as ALCAPA.
ALCAPA results in the left ventricular
myocardium being perfused by relatively
desaturated blood under low pressure, leading
to myocardial ischemia.
ALCAPA is a rare, congenital cardiac anomaly
accounting for approximately 0.25-0.5% of all
congenital heart diseases.
Approximately 85% of patients present with
clinical symptoms of CHF within the first 1-2
months of life.

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Myocardial bridging

Myocardial bridging is most commonly observed

of the LAD (figure).
The depth of the vessel under the myocardium
is more important that the lenght of the
myocardial bridging.
There is debate, whether some of these
myocardial bridges are hemodynamically
significant.

Fistula

On the image on the left we see a large LAD

giving rise to a large septal branch that
terminates in the right ventricle (blue arrow).

Left to right shunt: septal branch of LAD teminates in

right ventricle

1. Introduction to cardiothoracic imaging

by Carl Jaffe and Patrick J. Lynch
2. Cardiology Site
by M. Abdulla
This site includes instructional movies, 3-D animation, panoramic views, online quiz, interactive video-
clips, interactive heart sounds & murmurs and interactive echocardiograms.
3. Visualization of Anomalous Coronary Arteries on Dual Source Computed Tomography
by G.J. de Jonge et al
European Radiology, Volume 18, Number 11 / November, 2008, 2425-2432

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