Catheterization and Cardiovascular Diagnosis 25:148-150 (1 992)

Dual Origin of the Left Circumflex Coronary Artery: A Case Report

Mark Warner, MD, George Eapen, MD, and George W. Vetrovec, MD

We describe a patient with two separate vessels having different origins supplying the circumflex coronary artery distribution. This represents a previously undescribed coro- nary artery anomaly.

Key words: coronary artery anomalies, coronary angiography, cardiac catheterization

INTRODUCTION

Coronary artery anomalies have been reported to occur in between 0.64 and 1.3% of patients undergoing coro- nary arteriography [ 1,2]. We report the case of a patient whose circumflex coronary distribution was supplied by two arteries, one originating from the left aortic cusp and the other from the left main coronary artery. This anom- aly has not been previously reported.

CASE REPORT

A 52-yr-old black female with a history of hyperten- sion, diabetes mellitus, and left ventricular hypertrophy was referred for cardiac catheterization. She had been having substernal chest pains for the past several months, and was suspected to have significant coronary artery disease. She also had a history of frequent VPCs, and had suffered a stroke 15 years previously.

Cardiac catheterization was performed without diffi- culty using the right femoral approach. When attempting to engage her left coronary artery using a left Judkins catheter, a small vessel supplying her left posterior myo- cardium was initially cannulated. This artery could be entered by applying clockwise torque on the catheter. By applying counterclockwise torque, the left main coronary artery was entered. Her left main coronary artery bifur- cated into the left anterior descending coronary artery and another vessel which appeared to be a large first obtuse marginal branch (Fig. 1 ) . However, there was no atrioventricular groove continuation of the circumflex beyond this first marginal branch. The smaller vessel, which originated separately from the left coronary cusp of the aorta, appeared to run in the atrioventricular groove and to supply the distal circumflex distribution (Fig. 2). On most injections into the left main coronary artery, refluxed dye in the left coronary cusp opacified the aberrant vessel to some degree. This is demonstrated in Figure 3, which shows how both vessels together sup-

0 1992 Wiley-Liss, Inc.

ply the normal circumflex distribution. Interestingly, the patient’s right coronary artery had an aberrant origin from the aorta as well. The right coronary artery ostium was higher and more anterior than usual, and had to be entered using a left Amplatz 1 catheter.

DISCUSSION

There have been multiple studies in the literature de- scribing the incidence and types of coronary anomalies found in a population referred for cardiac catheterization. In the largest of these studies, Yamanaka and Hobbs reviewed 126,595 patients undergoing cardiac catheter- ization between 1960 and 1988 [ I ] . No patient was de- scribed as having a dual circumflex coronary artery orig- inating from both the left main trunk and the aorta. They described the separate origin of the left anterior descend- ing and the circumflex coronary arteries from the left sinus of Valsalva as being the most common coronary anomaly, occurring in 0.41% of the population. This was followed closely by the origination of the circumflex coronary artery from the right sinus of Valsalva or right coronary artery, occurring in 0.37% of the population. Together, these two variations accounted for 58% of all the anomalies detected. The only other anomaly involv- ing the circumflex coronary artery in their study was its absence, which occurred in the setting of a “super-dom- inant” right coronary artery.

Wilkins et al. reviewed the records of over 10,000 pateints who had undergone coronary angiography at the

From the Department of Medicine, Division of Cardiology, Medical College of Virginia, Richmond.

Received June 18, 1991; revision accepted August 18, 1991.

Address reprint requests to Mark Warner, MD. Box 36. MCV Station. Richmond, VA 23298.

Dual Circumflex Coronary Artery 149

Fig. 1. Shallow RAO view of the left coronary artery demon- strating how the left main bifurcates normally into the anterior descending and circumflex (closed arrow) coronary arteries. There is faint opacification of the aberrant vessel (open arrow).

Fig. 2. Shallow RAO view showing selective opacification of the aberrant circumflex branch.

Texas Heart Institute between 1974 and 1986 133. The most common anomaly was the origin of the circumflex coronary artery from the right coronary artery or right sinus of Valsalva. These authors did not report the sep- arate origin of the left anterior descending and circum-

Fig. 3. Shallow RAO view demonstrating opacification of both circumflex branches.

flex coronary arteries from the left sinus of Valsalva as being an anomaly. They also did not find any patient who had two separate circumflex coronary arteries. In our review of other angiographic studies reported in the literature, we also could not find any previous report of this anomaly [4-81.

Roberts reported a large review of coronary artery anomalies based on necropsy material and coronary an- giography [9]. He described one patient who had a sep- arate origin of the left anterior descending and left cir- cumflex coronary arteries from the aorta. This patient also had a large ramus intermedius vessel exiting the left main trunk. Angiographically, the circumflex vessel ex- iting the left main in our patient did not appear like an intermediate artery, in that it did not overlap the left anterior descending artery in the shallow RAO view (Fig. I) . However, since the patient reported by Roberts was discovered at necropsy, it is possible that his angi- ographic appearance might have been similar to that in our patient had he undergone coronary angiography prior to death.

This patient emphasizes the importance of reviewing the coronary angiograms during a catheterization to be certain that there is blood supply to all areas of the myo- cardium. If this is not the case, then further attempts at selective cannulation of a potential anomalous vessel should be considered. A complete and diagnostic study often depends on careful angiographer assessment of this relationship between vessels and area supplied during the catheterization procedure.

150 Warner et al.

In summary, we report a patient who was found to have two separate circumflex coronary arteries, one aris- ing from the left main coronary artery and the other from the aorta. This anomaly has not been previously reported in the angiographic literature, nor has it been seen before by any of the authors. We feel, therefore, that its inci- dence must be extremely rare.

REFERENCES

Yamanaka 0, Hobbs RE: Coronary artery anomalies in 126,595 patients undergoing coronary arteriography . Cathet Cardiovasc Di- agn 21:28-40, 1990. Kimbiris D, Iskandrian AS, Segal BL, Bemis CE: Anomalous aortic origin of coronary arteries. Circulation 58:606-616, 1978. Wilkins CE. Betancourt B, Mathur VS, Massumi A, DeCastro CM. Gracia E, Hall RJ: Coronary artery anomalies: A review of more than 10.000 patients from the Clayton Cardiovascular Lab- oratories. Tex Heart lnst J 15:166-173, 1988.

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