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CT Angiography of Coronary Arterial and Venous Anatomy

C a rd i a c I m ag i n g P i c t o r i a l E s s ay

Normal and Variant Coronary Arterial and Venous Anatomy on High-Resolution CT Angiography
Sunil Kini1, 2 Kostaki G. Bis2 Leroy Weaver2, 3
Kini S, Bis KG, Weaver L OBJECTIVE. This article displays the normal and variant anatomy of the coronary arteries and subjacent cardiac veins using a high-resolution 64-MDCT scanner. CONCLUSION. Knowledge of the anatomy of the coronary arteries and subjacent cardiac veins as displayed with maximum intensity and volume-rendered projections is important for correct image interpretation of coronary CT angiography examinations. ontrast-enhanced CT angiography (CTA) of the coronary arteries is becoming feasible as temporal and spatial resolution improves with the availability of MDCT. Detection, characterization, and quantification of coronary artery disease and elegant delineation of coronary anatomy are possible using 2D multiplanar reformation (MPR), 3D maximum-intensity-projection (MIP), and 3D volume-rendered postprocessing techniques. Familiarity with coronary artery and venous anatomy and anatomic variants is important for correct image interpretation. This anatomy and the arterial variants have been well described using conventional angiographic techniques [1, 2]. However, the cross-sectional nature of CT has the benefit of more precisely displaying the spatial relationships of coronary arterial and venous anatomy with respect to cardiac structures. This article highlights this anatomy with a variety of MIP and volume-rendered techniques (Figs. 118).

Keywords: anatomy, anomalies, arteriography, cardiac imaging, coronary arteries, CT angiography, heart, MDCT DOI:10.2214/AJR.06.1295 Received September 30, 2006; accepted after revision January 15, 2007.
1Present address: Quantum Medical

Radiology, Atlanta,

GA 30339.
2Department

Subjects and Methods

Coronary CTA protocols usually image the heart using cranial-to-caudal acquisition [3]. However, caudal-to-cranial scanning acquisitions are implemented when concomitant imaging of the pulmonary arteries is desired in patients with atypical chest pain [4]. We describe both of these protocols because the cardiac venous anatomy may be displayed with variation in enhancement depending on the type of data acquisition. The patients who participated in our study were imaged after the institutional review board had approved the study, which complies with the Health Insurance Portability and Accountability Act, and after

of Diagnostic Radiology, William Beaumont Hospital, 3601 W 13 Mile Rd., Royal Oak, MI 48073. Address correspondence to K. G. Bis (kbis@beaumont.edu). General Healthcare System,

3Present address: Elkhart

Elkhart, IN 46514. CME This article is available for CME credit. See www.arrs.org for more information. AJR 2007; 188:16651674 0361803X/07/18861665 American Roentgen Ray Society

they had provided written informed consent. Patients were recruited from October 2004 to June 2005. Imaging was performed on a 64-slice (32-detector) MDCT scanner (Sensation Cardiac 64, Siemens Medical Solutions) after the patient was premedicated with oral atenolol (50100 mg), IV metoprolol (5- to 10-mg boluses, up to 50 mg), or both. An upper extremity 20-gauge IV catheter was used for venous access. Sublingual nitroglycerin (0.4 mg) was provided to induce coronary vasodilatation. Bolus timing was measured in the mid ascending aorta with 20 mL of iodixanol (320 mgI/mL [Visipaque, GE Healthcare]) administered at a rate of 5 mL/s followed by a 50-mL saline flush, also administered at a rate of 5 mL/s). Alternatively, bolus tracking can be used to trigger data acquisition by placing a region of interest over the mid ascending aorta and setting the trigger threshold to 160 H above baseline. Single-sector reconstructions of the coronary arteries were performed at 65% and 35% of the R-R length and were then modified to a different phase start if there were motion artifacts. Reconstructions were performed on a workstation (Wizard, Siemens Medical Solutions) and then transferred to another workstation (TeraRecon, TeraRecon) for MPRs and MIPs. Cases were selected to show the normal coronary arterial and venous anatomy. MIPs were obtained using various thicknesses (530 mm) and were displayed using standard orientations (right anterior oblique, left anterior oblique, axial) with or without caudal or cranial angulation. Volume-rendered images were also obtained using various orientations.

Cranial-to-Caudal Acquisition
Coronary CTA was performed 5 seconds after aortic peak density; 100 mL of iodixanol (Visipaque) was administered at 5 mL/s and was fol-

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lowed by a 50-mL saline flush at 5 mL/s [3]. Retrospective ECG-gating was used with the following parameters: collimation, 0.6 mm; tube rotation time, 0.33 seconds; tube voltage, 120 mV; effective mAs, 750850; pitch, 0.2; and scanning time, 1012 seconds. Scanning coverage was from the level of the carina to the bottom of the heart. Reconstruction field of view, slice thickness and reconstruction increment, and smooth kernel were as follows: 1522 cm; 0.6 and 0.3 mm, respectively; and B25f. ECG pulsing is usually implemented for tube current modulation and is needed to reduce radiation exposure [5].

ventricle (RV), and the left coronary artery (LCA) supplies the anterior portion of the ventricular septum and anterior wall of the left ventricle (LV). The vessels that supply the remainder of the LV vary depending on the coronary dominance, which we explain later. RCA Anatomy The RCA arises from the right coronary sinus somewhat inferior to the origin of the LCA. After its origin from the aorta, the RCA passes to the right of and posterior to the pulmonary artery and then emerges from under the right atrial appendage to travel in the anterior (right) atrioventricular (AV) groove (Figs. 1 and 2). In about half of the cases, the conus branch is the first branch of the RCA (Fig. 3). In the other half, the conus branch has an origin that is separate from the aorta. The conus branch always courses anteriorly to supply the pulmonary outflow tract. Occasionally, the conus branch can be a branch of the LCA (Fig. 3D), have a common origin with the RCA, or have dual or multiple branches. In 55% of cases, the sinoatrial nodal artery (Figs. 3C, 3D, and 4A) is the next branch of the RCA, arising within a few millimeters of the RCA origin. In the remaining 45% of cases, the sinoatrial nodal artery arises from the proximal left circumflex (LCx) artery (Figs. 4B and 11). In either case, the sinoatrial nodal artery always courses toward the superior vena cava inflow near the cephalad aspect of the interatrial septum. As the RCA travels within the anterior AV groove, it courses downward toward the posterior (inferior) interventricular septum. As it does this, the RCA gives off branches that supply the RV myocardium; these branches are called RV marginals or acute marginals (Fig. 5). They supply the RV anterior wall. After it gives off the RV marginals, the RCA continues around the perimeter of the right heart in the anterior AV groove and courses toward the diaphragmatic aspect of the heart. Coronary Dominance The artery that supplies the posterior descending artery (PDA) and the posterolateral branch determines the coronary dominance. If the PDA and PLB arise from the RCA, then the system is said to be right dominant (8085% of cases) (Figs. 6 and 7). In this instance, the RCA supplies the inferoseptal and inferior segments of the LV [6]. If the PDA and PLB arise from the LCx artery, then the system is said to be left dominant (1520% of cases) (Figs. 8 and 17). In this instance, the LCA supplies the

Caudal-to-Cranial Acquisition
For the caudal-to-cranial acquisition, a patient preparation and scanning protocol similar to that described in the previous section was used. However, contrast injection was performed with a higher volume of contrast material using a biphasic protocol: 100 mL of iodixanol was administered at 5 mL/s followed by 30 mL of iodixanol at 3.0 mL/s and then a 50-mL saline flush at 3 mL/s. The additional volume of contrast material resulted in a prolonged time for contrast injection to ensure adequate enhancement of the pulmonary arteries [4]. As a result, streak artifacts arising from the superior vena cava and right atrium were present in 37 (88%) of 42 studies; however, these artifacts interfered with the visualization of the right coronary artery (RCA) in only one (2.4%) of the 42 cases [4]. The thorax from the lung bases to just above (12 cm) the aortic arch was scanned with a 12- to 15-second acquisition (no ECG pulsing), but scanning can include the entire thorax when ECG pulsing is applied. As with cranial-to-caudal acquisitions, ECG pulsing is needed to reduce radiation exposure [5]. Reconstruction field of view, slice thickness and reconstruction increment, and kernel for the coronary arteries were similar to those for the cranial-to-caudal acquisition. However, reconstructions were also obtained with a larger field of view [4] to display the pulmonary arteries, thoracic aorta, lungs, and thoracic soft tissues.

inferoseptal and inferior segments of the LV. If the PDA comes from the RCA and the PLB comes from the LCx artery, the system is codominant (about 5% of cases) (Fig. 9). In left-dominant and codominant systems, the LCx artery continues in the posterior AV groove as the left AV groove artery and gives rise to left PLB. In left dominance, the PDA is the final branch of the AV groove artery. The distal RCA divides into the PDA and PLB in a right-dominant system. The nondominant system is usually noticeably smaller in caliber than the dominant system. This difference in caliber can be used as an additional clue to determine whether the coronary anatomy is right or left dominant. Usually arising just distal to the origin of the PDA, the AV nodal artery (Fig. 6) can be recognized by its direct vertical course off of the distal RCA. In cases of left dominance, the AV node branch has a similar appearance and location, but it arises just proximal to the (left) PDA. LCA Anatomy The LCA normally emerges from the left coronary sinus as the left main (LM) coronary artery (Fig. 10). The LM coronary artery is short (510 mm), passes to the left of and posterior to the pulmonary trunk, and bifurcates into the left anterior descending (LAD) and LCx arteries (Fig. 11). Occasionally, the LM coronary artery trifurcates into the LAD artery, the LCx artery, and the ramus intermedius artery (Fig. 12). Ramus Intermedius Artery The most common variation in LCA anatomy is the presence of a trifurcation of the LM coronary artery. In this instance, the LM coronary artery trifurcates into the LAD artery, LCx arteries, and an artery between them called the ramus intermedius artery (Fig. 12). The ramus intermedius artery itself has variable branching. The ramus intermedius can be distributed as a diagonal branch or as an obtuse marginal branch depending on whether it supplies the anterior or the lateral wall, respectively. LAD Artery The LAD artery (Fig. 13) runs in the anterior interventricular sulcus along the ventricular septum. Commonly, the LAD artery may be embedded within the anterior myocardium forming an overlying myocardial bridge (Fig. 14). Myocardial bridging is seen more often on CT than described in the coronary angiography literature. Most myocardial bridges are asymptomatic, although rarely myocardial

Normal Anatomy of the Coronary Arteries The right and left coronary arteries originate from the right and left sinuses of Valsalva of the aortic root, respectively. The posterior sinus rarely gives rise to a coronary artery and is referred to as the noncoronary sinus. The locations of the sinuses are anatomic misnomers: The right sinus is actually anterior in location and the left sinus is posterior. The myocardial distribution of the coronary arteries is somewhat variable, but the right coronary artery (RCA) almost always supplies the right

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CT Angiography of Coronary Arterial and Venous Anatomy bridging can be associated with ischemia. The LAD artery has branches called septal perforators (Fig. 14) that supply the anterior ventricular septum. It also has diagonal arteries (Fig. 15) that course over and supply the anterior wall of the LV. The diagonals and septal perforators are numbered sequentially from proximal to distal (i.e., D1, D2, S1, S2). LCx Artery The LCx artery (Figs. 16, 17, and 2, 4B, 8, 11, 12, 15) runs in the posterior AV groove analogous to the course of the RCA on the opposite side. The major branches of the LCx artery consist of obtuse marginals (OMs) (Figs. 16 and 17). OM branches supply the lateral wall of the LV. They are numbered sequentially from proximal to distal (i.e., OM1, OM2, OM3). Anomalies of RCA Origin The RCA can have an anomalous origin. It is important to be aware of this possibility to avoid misinterpreting coronary CTA. Typically, the anomalous origin of the RCA is from the left coronary sinus of Valsalva, with a subsequent course between the aortic root and right ventricular outflow tract. Depiction of these anomalies is beyond the scope of this article; however, this and other anomalies of RCA origin are described by Kim et al. [7]. An example of an anomalous origin of the RCA is shown in Figure 18. Anomalies of LCA Origin The LCA and its branches can have an anomalous origin. It is important to be aware of this possibility to avoid misinterpreting coronary CTA. Some of these anomalies are associated with an increased risk of sudden death or cardiac arrest (Fig. 18C). Depiction of these anomalies is beyond the scope of this article; however, anomalies of LM, LAD, and LCx origin are reviewed by Kim et al. [7]. Coronary Venous Anatomy The great cardiac vein (Figs. 4B and 16A) is located in the anterior interventricular sulcus, alongside the LAD artery. It courses upward from the apex and drains into the coronary sinus. The middle cardiac vein (Figs. 7A and 7C) also begins at the apex, but it courses upward in the inferior interventricular sulcus, alongside the PDA. Between the two, there is a variable posterolateral vein (Fig. 7C) draining the lateral wall of the LV. The coronary sinus (Figs. 7A, 7C, 16A, and 16B) is the wide vein that courses in the posterior AV groove accompanying the LCx artery and the AV groove artery. It drains into the right atrium and receives the great cardiac vein proximally and the middle cardiac vein distally. Reporting System of Coronary Artery Disease In an attempt to standardize the reporting of coronary artery disease, an ad hoc committee of the American Heart Association developed nomenclature and further divided the main coronary arteries into proximal, middle, and distal segments [8]. The proximal RCA segment is from the ostium to one half the distance to the acute margin of the heart. The middle RCA segment is the RCA from the end of the above segment to the acute margin of heart. The distal RCA segment is the RCA running along the right AV groove from the acute margin to the origin of the PDA. The LAD proximal segment is proximal to and includes the origin of the first major septal perforator. The middle LAD segment is the LAD artery immediately distal to the origin of the first major septal perforator that extends to the point where the LAD artery forms an angle (right anterior oblique view). This angle is often, but not always, close to the origin of the second diagonal. If this angle or diagonal is not identifiable, this segment ends one half the distance from the first major septal perforator to the apex. The apical LAD segment is the terminal portion of the LAD artery that begins at the end of the previous segment and extends to or beyond the apex. The proximal LCx segment is the mainstem of the LCx artery from its origin off the LCA to and including the origin of an obtuse marginal. The distal LCx segment is the LCx artery distal to the origin of the obtuse marginal and travels along or close to the posterior AV groove. Conclusion Coronary CTA is emerging as an essential imaging tool for evaluating the coronary arteries. Knowledge of the CT appearance of the coronary anatomy and various coronary artery anomalies is essential for accurate diagnosis and proper patient treatment.

References
1. Green CE. Coronary cinematography. Philadelphia, PA: Lippincott-Raven, 1996 2. Soto B, Russell RO, Moraski RE. Radiography anatomy of the coronary arteries: an atlas. Mount Kisco, NY: Fitura Publishing, 1976 3. Raff GL, Gallagher MJ, ONeil WW, Goldstein JA. Diagnostic accuracy of noninvasive coronary angiography using 64-slice computed tomography. J Am Coll Cardiol 2005; 46:552557 4. Vrachliotis TG, Bis KG, Hardary A, et al. Enhancement of coronary, aortic and pulmonary vasculature using biphasic single-injection 64-slice CT: angiography protocol in emergency department patients with atypical chest pain. Radiology (forthcoming, May 2007) 5. Jakobs TF, Becker CR, Ohnesorge B, et al. Multislice helical CT of the heart with retrospective ECG gating: reduction of radiation exposure by ECG-controlled tube current modulation. Eur Radiol 2002; 12:10811086 6. Cerqueira MD, Weisman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 2002; 105:539547 7. Kim SY, Seo JB, Do KH, et al. Coronary artery anomalies: classification and ECG-gated multi-detector row CT findings with angiographic correlation. RadioGraphics 2006; 26:317334 8. Austen WG, Edwards JE, Frye RL, et al. A reporting system on patients evaluated for coronary artery disease: Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 1975; 51[suppl 4]:540

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Fig. 1Anterior schematic diagram of heart shows course of dominant right coronary artery and its tributaries. AV = atrioventricular, PDA = posterior descending artery, RCA = right coronary artery, RV = right ventricular, SA = sinoatrial.

B
Fig. 2CT images of normal heart in 53-year-old man. Ao = aortic root, CS = coronary sinus, LA = left atrium, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, LV = left ventricle, PDA = posterior descending artery, RA = right atrium, RCA = right coronary artery, RV = right ventricle, RVOT = right ventricular outflow tract. A, Axial 5-mm maximum-intensity-projection (MIP) image shows left main coronary artery as it arises from left coronary cusp. B, Axial 5-mm MIP image shows right coronary artery as it arises from right coronary cusp inferior to level of beginning of left main coronary artery. C, Axial 5-mm MIP image shows course of right coronary artery within anterior atrioventricular groove. Left anterior descending artery is shown within anterior interventricular groove, and left circumflex artery is shown in posterior atrioventricular groove. D, Axial 5-mm MIP image shows origin of posterior descending artery from distal right coronary artery.

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Fig. 3Conus branch anatomy variations. Ao = aortic root, LA = left atrium, LAD = left anterior descending artery, LM = left main coronary artery, LV = left ventricle, RA = right atrium, RCA = right coronary artery, RVOT = right ventricular outflow tract, SAN = sinoatrial node branch. A, Left anterior oblique 5-mm maximum-intensityprojection (MIP) image shows conus branch (arrow) in 44-year-old woman as it arises separate from right coronary artery off of right coronary cusp. B, Left anterior oblique 15-mm MIP image shows common origin of conus branch (arrow) and right coronary artery in 40-year-old man. C, Axial 10-mm MIP image shows conus branch (arrow) arising from proximal RCA in 52-year-old man. It then courses anteriorly toward right ventricular outflow tract. D, Axial 10-mm MIP image shows conus branch (arrow) arising from left anterior descending artery in 46-year-old man.

Fig. 4Sinoatrial node branch variations. Ao = aortic root, D1 = first diagonal, GCV = great cardiac vein, LA = left atrium, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, OM1 = first obtuse marginal, RCA = right coronary artery, RVOT = right ventricular outflow tract, SVC = superior vena cava. A, Axial 10-mm maximum-intensity-projection (MIP) image in 64-year-old man shows large sinoatrial node branch (arrow) as it arises from proximal right coronary artery. It then courses posteriorly toward cephalad aspect of interatrial septum (arrowheads) posterior to inflow of superior vena cava. B, Axial 10-mm MIP image shows sinoatrial node branch (arrow) in 65-year-old woman as it arises from proximal left circumflex artery: Sinoatrial branch still courses toward cephalad aspect of interatrial septum.

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B
Fig. 6Distal right coronary artery anatomy in 34-yearold man. Left anterior oblique 20-mm maximumintensity-projection image shows course of entire right coronary artery. Distally, posterior descending artery and posterior lateral branch are shown, as is atrioventricular node branch. Ao = aortic root, AVN = atrioventricular node, IMB = inferior marginal branch, LCx = left circumflex artery, LV = left ventricle, PDA = posterior descending artery, PLB = posterior lateral branch, RCA = right coronary artery, RVOT = right ventricular outflow tract.

Fig. 5Marginal branch anatomy. F = foot, LAD = left anterior descending artery, LV = left ventricle, RCA = right coronary artery, RV = right ventricle. A, Right anterior oblique 10-mm maximum-intensity-projection (MIP) image shows large marginal branch (arrow) arising from right coronary artery (RCA) in 40-year-old woman. B, Right anterior oblique volume-rendered image shows marginal branch (arrow) of RCA as it courses over right ventricle in 45-year-old woman.

Fig. 7Distal dominant right coronary artery variation on axial projections. CS = coronary sinus, LV = left ventricle, MCV = middle cardiac vein, PDA = posterior descending artery, PLB = posterior lateral branch, PLV = posterolateral vein, RA = right atrium, RCA = right coronary artery, RV = right ventricle. A, Axial 10-mm maximum-intensity-projection (MIP) image in 51-year-old man shows typical tortuous course of posterior descending artery as it arises from distal right coronary artery. Posterior descending artery travels in inferior interventricular groove along side middle cardiac vein. Posterior lateral branch continues along distal coronary sinus to supply inferior wall. B, Axial 10-mm MIP image shows dual posterior descending arteries and dual posterior lateral branches in 44-year-old man. C, Axial 3D volume-rendered projection image shows origin of posterior descending artery, which still courses toward middle cardiac vein, is higher than normal in 49-yearold woman.

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Fig. 8Dominant left circumflex artery and posterior descending artery anatomy. Ao = aortic root, AVGA = atrioventricular groove artery, CS = coronary sinus, LA = left atrium, OM = obtuse marginal, PDA = posterior descending artery, PLB = posterior lateral branch, RA = right atrium, RCA = right coronary artery. A and B, Left anterior oblique 10-mm maximum-intensity-projection (MIP) images show two examples of dominant left circumflex artery anatomy with typical small nature of right coronary artery: one in 43-year-old woman (A) and one in 44-year-old man (B). Atrioventricular groove artery descends as larger-caliber artery in posterior atrioventricular groove subjacent to coronary sinus. C, Axial 10-mm MIP image shows dual posterior descending arteries as they arise from distal atrioventricular groove artery in 44-year-old man with dominant left circumflex artery.

Fig. 9Codominance. Axial 10-mm maximumintensity-projection image reveals codominant anatomy in which posterior descending artery arises from right coronary artery and posterior lateral branch arises from distal left circumflex artery in 33-year-old man. LV = left ventricle, PDA = posterior descending artery, PLB = posterior lateral branch, RCA = right coronary artery, RV = right ventricle.

Fig. 10Dominant left coronary artery anatomy. Left anterior oblique schematic diagram of dominant left coronary artery anatomy, including left anterior descending artery and left circumflex artery tributaries, is shown. AVGA = atrioventricular groove artery, PDA = posterior descending artery.

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Fig. 11Left main coronary artery bifurcation. Anterior caudal 10-mm maximum-intensity-projection image displays typical bifurcation of left main coronary artery into left anterior descending and left circumflex arteries in 47-year-old man. AVGA = atrioventricular groove artery, D1 = first diagonal, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, OM1 = first obtuse marginal, SAN = sinoatrial node branch.

Fig. 12Ramus intermedius anatomy. LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, RI = ramus intermedius artery. A, Right anterior oblique caudal 10-mm maximum-intensity-projection (MIP) image displays trifurcation of left main coronary artery into left anterior descending artery, ramus intermedius artery, and left circumflex artery in 49-year-old man. B, Axial 10-mm MIP image shows left main coronary artery dividing into left anterior descending artery, left circumflex artery, and ramus intermedius branches in 42-yearold woman. C, Left posterior cranial 3D volume-rendered projection image shows branching ramus intermedius artery, which is mostly distributed as obtuse marginal branch to lateral wall, in 52-year-old man.

Fig. 13Left anterior descending artery course. Right anterior oblique 10-mm maximum-intensity-projection image reveals entire course of left anterior descending artery within anterior interventricular groove in 44year-old woman. Distally, it is seen wrapping around left ventricular apex (arrows). LA = left atrium, LV = left ventricle.

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Fig. 14Myocardial bridge and septal perforator branch anatomy in 39-year-old woman. LA = left atrium, LAA = left atrial appendage, LV = left ventricle, S1, S2, S3 = first, second, and third septal perforators. A, Right anterior oblique 10-mm maximum-intensityprojection (MIP) image displays left anterior descending artery and septal perforator branches. Myocardial bridge overlies left anterior descending artery just beyond second septal perforator (arrows). B, Short-axis (left anterior oblique) 5-mm MIP image at level of myocardial bridge shows left anterior descending artery (arrow) deep to right ventricular myocardium junction with left ventricle.

Fig. 15Diagonal branch anatomy. D1 = first diagonal, D2 = second diagonal, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, LV = left ventricle, RI = ramus intermedius artery, SP = septal perforator branches. A, Axial caudal oblique 10-mm maximum-intensityprojection (MIP) image reveals two diagonal branches (D1 and D2) from left anterior descending artery in 55year-old man. Diagonal branches course laterally, and small septal perforator branches course medially. B, Cranial left anterior oblique 10-mm MIP image shows left anterior descending artery and two diagonal branches in 47-year-old man.

Fig. 16Nondominant left circumflex artery anatomy in 36-year-old man. AVGA = atrioventricular groove artery, CS = coronary sinus, D1 = first diagonal, GCV = great cardiac vein, LAD = left anterior descending artery, LCx = left circumflex artery, OM1 = first obtuse marginal. A, Axial 10-mm maximum-intensity-projection (MIP) image shows left circumflex artery and left anterior descending artery with large first obtuse marginal arising from proximal left circumflex artery. Small left circumflex artery descends in posterior atrioventricular groove as atrioventricular groove artery. B, Left anterior oblique 10-mm MIP image displays left circumflex artery anatomy with its descent as atrioventricular groove artery.

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Fig. 17Dominant left circumflex artery anatomy in 44-year-old man. AVGA = atrioventricular groove artery, LCx = left circumflex artery, LM = left main coronary artery, OM1 = first obtuse marginal, OM2 = second obtuse marginal, PDA = posterior descending artery, PLB = posterior lateral branch, RI = ramus intermedius artery. A, Left anterior oblique cranial 3D volume-rendered image shows dominant left circumflex artery anatomy with two obtuse marginal branches. B, Axial 3D volume-rendered image reveals dual posterior descending artery and posterior lateral branch arising from distal atrioventricular groove artery.

Fig. 18Anomalous origin of right coronary artery and left main coronary artery. Ao = aortic root, LAD = left anterior descending artery, LM = left main coronary artery, RCA = right coronary artery, RVOT = right ventricular outflow tract. A, Axial 5-mm maximum-intensity-projection (MIP) image shows anomalous origin of right coronary artery in 43-year-old woman from anterior proximal ascending aorta with subsequent acute rightward course before reaching anterior atrioventricular groove. B, Three-dimensional volume-rendered projection image shows anomalous right coronary artery in same patient as A above level of right coronary cusp (arrow). C, Axial 10-mm MIP image reveals anomalous origin of left main coronary artery in 35-year-old man from right cusp near origin of right coronary artery. It then takes intraseptal course posterior to right ventricular outflow tract near cephalad aspect of interventricular septum.

F O R YO U R I N F O R M AT I O N

This article is available for CME credit. See www.arrs.org for more information.

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