Coronary anatomy and anomalies

https://radiologyassistant.nl/cardiovascular/anatomy/coronary-anatomy-and-anomalies
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)
• 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)
• 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)
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 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.
• The LCA divides almost immediately into the circumflex artery (Cx) and left anterior descending
artery (LAD).
• The LCA travels between the right ventricle outflow tract anteriorly and the left atrium
posteriorly and 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)
• 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)

• 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.
• 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 ventricle.
Right Coronary Artery (RCA)

• 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.
• 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.
• 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).