Sol sirkumfleks arterin devamı olarak seyreden oldukça nadir bir sağ koroner arter anomalisi: tekli koroner arter olgusu

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Introduction
The situation with single coronary aortic ostium for
whole coronary blood flow is called a single coronary
artery (1). This is an extremely rare anomaly and reported in 0.024% to 0.066% of cases performed conventional coronary angiography (2). This kind of anomaly
has shown many variations in coronary origination
and distribution. Herein, we describe an extremely
rare case of severe atherosclerotic single coronary artery with an anomalous right coronary artery arising
from the distal part of the left circumflex artery.
Case Report
A 72-year-old woman was admitted to our hospital
with exertional angina pectoris (CCS class II) lasting
for 6 months. She had a history of hypertension for
10 years. On her physical examination blood pressure
was 140/80 mmHg, and heart rate was 70 bpm and
regular. A 12-lead resting electrocardiogram and routine biochemical values were within normal limits.
Transthoracic echocardiography did not demonstrate any regional wall motion abnormality with normal left ventricular function. Because of the typical
chest pain on exertion a treadmill exercise test was
performed. During treadmill exercise test, 2 mm
downsloping ST segment depression in leads V5 and
V6 was observed at the stage-3. Subsequently, the
patient underwent selective coronary angiography.
Conventional coronary angiography revealed that the
left anterior descending artery (LAD) and left circumflex artery (CX) originated from their usual coronary
sinus but the right coronary artery (RCA) arose as a terminal extension of left circumflex artery and followed
retrogradely the course of the normal RCA territory
(Figure 1A,B). Nevertheless, RCA was not cannulated
in its usual location, then we performed aortagraphy
(Figure 2). It showed the absence of right coronary
ostium. Therefore, we noticed that all three coronary
arteries originated from the left coronary cusp.In addition, we observed a trifurcation lesion of
90% diameter stenoses in midsegment of LAD at
the level of first septal branch and the first diagonal
branch. Percutaneous coronary intervention decision was made, but the patient did not accept any coronary intervention after being informed about the
options and potential risks., The patient was, then,
discharged with a proper medical treatment.
Discussion
In many angiographic series, the incidence of congenital coronary artery anomalies may show discrepancies. The incidence of anomalous RCA in congenital coronary anomalies is variable in different
populations, with the highest incidence in Indian
(0.46%) and the lowest incidence in German (0.04%)
populations (3,4). Nonetheless, it was reported by
0.09% in the Turkish population with no mention of
single coronary artery (5).
Single coronary artery is defined as a single coronary aortic ostium to deliver blood flow to all three
coronary arteries and shows some degree of coronary origination and distribution differences. Single
coronary artery shows somewhat associations with
other congenital cardiac anomalies such as bicuspid
aortic valve and coronary arteriovenous fistula (6).
Although several case reports have been published
showing the arising of RCA form the LAD (7), there
are relatively less data about the arising of RCA as an
extension of the CX. According to the single coronary artery classification in literature by Lipton et al.
(1), our case is classified as Grup L1 since RCA arose
as a terminal extension of CX.
Single coronary artery anomalies which were found
incidentally during conventional coronary angigraphy remain mostly asymptomatic. It may not cause
any disorder in the blood distribution unless there is
a stenotic lesion. Ten cases have been reported describing the arising of RCA as an extension of the CX
in the literature (Table 1) (8-15), and none of these
had any atherosclerotic lesion. In our case, the patient had an atherosclerotic stenosis in LAD. Because of
no association between specific coronary artery anomaly and coronary artery disease, we considered that
atherosclerotic process in the LAD of the patient was
only a co-incidence. To the best of our knowledge, itis the first case showing this co-incidence. Our case
was the oldest one among these cases with RCA anomaly arising from CX and it might be the reason for
atherosclerosis in the LAD.
In conclusion, the RCA arising as a terminal extension of left CX is a relatively uncommon congenital
coroner artery anomaly. The cardiologist should be
kept in mind the likelihood of this and the other possible anomalies when performing a coronary angiography to make an accurate and complete diagnosis.