Coronary Arteries

Right Coronary Artery

- Origin: Right aortic sinus

- Course: Runs between the pulmonary trunk and right auricle and descends vertically
to the right anterior atrioventricular groove/coronary sulcus up to the junction of the
right and inferior border of the heart. At the inferior border of the heart, it turns
posteriorly and runs into the posterior atrioventricular groove up to the posterior
interventricular groove. It terminates by anastomosing with the left coronary artery.

- Branches
1) Right conus artery – supplies the anterior surface of pulmonary conus
2) Anterior ventricular branches – supplies the anterior surface of right ventricle
● Marginal branch is the largest and runs along the lower margin of the
sternocostal surface to reach the apex.
3) Atrial branches
● Artery of sinoatrial node (60% of cases)
4) Posterior ventricular branches – supplies the diaphragmatic surface of the right
and left ventricles
5) Posterior descending artery (posterior interventricular artery) – runs in the
posterior interventricular groove up to the apex and supplies the posterior part
of the IVS, AV node (60% of cases), and right and left ventricles.

Left Coronary Artery

- Origin: Left posterior aortic sinus of the ascending aorta above the aortic valve.

- Course: Runs between the pulmonary trunk and left auricle and divides into the
anterior descending artery (anterior interventricular artery) and descends vertically to
the left anterior interventricular groove up to the apex of the heart, where it turns
posteriorly to enter the posterior interventricular groove. It terminates by
anastomosing with the posterior interventricular artery (branch of the right coronary
artery). The circumflex artery winds around the left margin of the heart and continues
into the left posterior coronary sulcus up to the posterior interventricular groove. It
terminates by anastomosing with the right coronary artery.

- Branches
 1) Left anterior descending artery (anterior interventricular artery) – supplies the
anterior part of the IVS, greater part of the right ventricle and part of the left
ventricle, and part of the left AV bundle (bundle of Hiss).
2) Circumflex artery – gives a left marginal artery that supplies the left margin of
the left ventricle up to the apex of the heart.
3) Diagonal artery
4) Conus artery – supplies the pulmonary conus.
5) Atrial branches – supply the left atrium.

Clinical Correlation

- Angina Pectoris: If the coronary arteries are narrowed, the blood supply to the cardiac
muscle is reduced. As a result, on exertion, the patient feels severe pain in the region
of the left precordium for ~20 minutes. The pain is often referred to the left shoulder
and medial side of the arm and forearm. Pain occurs on exertion and is relieved by
rest.

- Myocardial Infarction: A sudden block of one the largest branches of the coronary
artery usually leads to myocardial ischemia followed by myocardial necrosis. The part
of the heart suffering from MI stops functioning and often causes death– heart attack
or coronary attack. MI mostly occurs at rest.

● Clinical features
1. Sensation of pressure/sinking and pain in the chest that last more than 30
minutes.
2. Nausea or vomiting, sweating, shortness of breath and tachycardia.
3. Pain radiates to the medial side of the arm, forearm and hand. Sometimes
it may be referred to the jaw or neck.
4. If PDA is damaged – low blood pressure; tachycardia.

- AP – plaque not ruptured, vessels are not totally occluded.

- MI – plaque ruptured, thrombocytes are clotted, vessels are totally occluded.

- Common sites of coronary artery occlusion

1. Left anterior descending artery (anterior interventricular artery) – 40-50%
2. Right coronary artery – 30-40%
3. Circumflex branch of the left coronary artery – 15-20%
Venous Drainage

- The venous blood of the heart is drained into the right atrium by coronary sinus,
anterior cardiac veins, venae cordis minimae (thebasian veins).

Coronary Sinus

- The principal and largest vein of the heart, lying in the posterior part of the
atrioventricular groove.

- It develops from the left horn of the sinus venosus and a part of the left common
cardinal vein.

- Most of the venous blood from the wall of the heart is drained into the right atrium
through the coronary sinus.

Tributaries

1. Great cardiac vein – accompanies the anterior descending and circumflex arteries to
join the left end of the coronary sinus.

2. Middle cardiac vein – accompanies the posterior interventricular artery.

3. Small cardiac vein – accompanies the right marginal artery.

4. Posterior vein of the left ventricle – runs on the diaphragmatic surface of the left
ventricle and joins the sinus to the middle cardiac vein.

5. Oblique veins of left atrium (vein of Marshall) – runs downwards on the posterior
surface of left atrium to enter the left end of the coronary sinus. It develops from the
left common cardinal vein (duct of Cuvier).

6. Right marginal vein – accompanies the marginal branch of the right coronary artery
and joins small cardiac vein and drains directly into the right atrium.

7. Left marginal vein – accompanies the marginal branch of the left coronary artery.

Anterior Cardiac Veins

 - A series of small veins that run parallel to each other across the surface of the right
ventricle to open into the right atrium.

Venae Cordis Minimae

- Extremely small veins in the walls of the chamber of the heart.

The Aorta

- The aorta begins at the left ventricle and terminates at the level of L4.

- Four main sections of the aorta: ascending aorta, aortic arch, thoracic (descending)
aorta and abdominal aorta.

- Course: originates to the right of the pulmonary trunk from the left ventricle. The aortic
arch bends in dorsal direction over the right pulmonary artery and runs in the upper
part of thorax, left of the vertebral column and next to the esophagus, it then lies
anterior of the vertebral column at the level of the diaphragmatic aperture, which lies
more caudal and ventral than the esophagus and inferior vena cava openings. Upon
passage through the diaphragm, the aorta is bordered by bundles of diaphragm
muscle (crux diafragmatica) arching around it, it then lies in the abdomen directly
ventral to the vertebral column, to the left of the inferior vena cava and splits (aortic
bifurcation) at the level of L4.

Ascending Aorta

- Origin: Aortic orifice

- Location: Middle mediastinum
- Length: 2 in or 5 cm
- Branches
1. Right coronary artery
2. Left coronary artery

- It travels along with the pulmonary trunk within the pericardial sheath.

Aortic arch

- Origin: 2nd sternocostal joint

- Termination: T4
- Location: Superior mediastinum
 - Length: 5 cm
- Branches
1. Brachiocephalic trunk
● Right common carotid artery and right subclavian artery – supply the right
side of the head, neck and upper limb.
2. Left common carotid artery – supplies the left side of the head and neck.
3. Left subclavian artery – supplies the left upper limb.
- It arches superiorly, posteriorly and inferiorly.
- It is connected to the pulmonary trunk by the ligamentum arteriosum.

Thoracic (descending) Aorta

- Origin: T4
- Termination: T12
- Location: Posterior mediastinum
- Length:
- Branches
1. Bronchial arteries
2. Mediastinal arteries
3. Esophageal arteries
4. Pericardial arteries
5. Superior phrenic arteries – supply the superior diaphragm
6. Intercostal and subcostal arteries – 9 pairs

- Initially begins to the left of the vertebral column but approaches the midline as it
descends.
- It exits the thorax via the aortic hiatus in the diaphragm where it becomes the
abdominal aorta.

Abdominal Aorta

- Origin: T12
- Termination: L4
- Location:
- Length:
- Branches
1. Inferior phrenic arteries – supply the diaphragm.
– unpaired anterior –
2. Celiac trunk (T12) – supplies the foregut.
3. Superior mesenteric artery (L1) – supplies the midgut.
 4. Inferior mesenteric artery (L3) – supplies the hindgut.
5. Middle suprarenal artery
6. Renal arteries
7. Gonadal arteries
8. Median sacral artery
9. Lumbar arteries

- It terminates by bifurcating into the right and left common iliac arteries that supply the
lower limbs.

Aortic Dissection

- An aortic dissection is a serious condition which occurs when there is injury in the
innermost wall; the tunica intima of the aorta.

- This tear creates 2 channels for blood flow:

A) Normal lumen of the aorta
B) Into the wall where blood remains stationary.

- The blood that remains in the wall can result in constriction of the aortic lumen leading
to a reduction of blood flow to the rest of the body.

- Site: occur anywhere along the aorta but the most common site is the beginning of the
ascending aorta.

- Clinical picture: tearing chest pain which radiates to the back, stroke or mesenteric
ischemia.

- Causes: chronic hypertension, a weakened aortic wall (due to Marfan syndrome,

pathological processes, or an aortic aneurysm).

- Investigations: CT angiogram, MRI angiograms, and transesophageal echocardio.

- Treatment:

Type A Type B
Ascending aorta Descending aorta
Surgically remove the dissected aorta Similarly surgery as type A with addition
in order to stop blood from leaking of a stent
 into the aortic wall and a graft is then
used to reconstruct the aorta
Medications are used to reduce heart Lifelong medications are used to control
rate and lower blood pressure blood pressure

Aortic Aneurysm

- An aortic aneurysm is a balloon-like bulge or dilation of the aorta to more than 50%
times its normal diameter.

- Site: occur anywhere in your aorta but the most common site is the abdominal aorta–
triple A (abdominal aortic aneurysm).

- Clinical picture: back pain, abdominal pain, abdominal pulsations, pain and numbness
in the lower limbs (due to compression of the nerve root).

- Causes: underlying weakness of the vessel walls, Marfan syndrome, pathological

processes, aortic dissection, males smokers above 60-65 need abdominal U/S

- Investigations: U/S.

- Treatment: surgical replacement of the weakened vessel wall with a piece of synthetic
tubing.

- Aortic aneurysms that are small usually do not present immediate threat however if
left untreated a large aneurysm can rupture, this is a medical emergency and is often
fatal.

- Aortic arch aneurysm may cause a hoarse voice due to involvement of the left
recurrent laryngeal nerve which wraps around the aortic arch.

- Left and right atria are close to the laryngeal nerve causing dilation.