Computed tomographic angiography identification of intramural segments in anomalous coronary arteries with interarterial course

Abstract

Certain coronary anomalies are associated with high risk features. We sought to determine the diagnostic accuracy of coronary computed tomographic angiography (CTA) in determining high-risk features, particularly intramural segments. Anomalous coronary arteries can be associated with adverse clinical events. Anomalous coronaries that course between the great vessels (interarterial) have been associated with sudden death. High-risk features of interarterial vessels described in the literature include; a slit-like orifice, acute angle of origin, and intramural segments (within the wall of the aorta). Although computed tomography (CT) findings of acute angle and slit like orifice have been described previously no prior evaluations regarding CT identification of an intramural segment have been reported. An intramural segment has distinct surgical management implications. All interarterial anomalous coronary arteries do not have an intramural segment. Since October 2004, 15 patients were diagnosed by CTA as having an anomalous coronary artery with an interarterial course, which were then confirmed by intraoperative examination of their coronary origins and course during aortic root/coronary artery surgery. The CTA images were retrospectively analyzed for the presence of high-risk features by a radiologist blinded to the surgical findings. Comparison of these findings was made to the findings at surgery. The anomalous coronary was the right coronary artery in 10 patients and the left coronary artery in 5. Eleven patients had an intramural segment identified at surgery. Pre-operative coronary CTA showed that all patients with an intramural course of the anomalous artery, had slit-like orifice, an acute angle of origin (mean 18.4 ± 3.4°), and an elliptical shaped cross-section throughout the intramural segment of the anomalous vessel. The average vessel height/width ratio for anomalous coronary vessels without an intramural segment was 1.03; compared to a ratio of 2.19 for anomalous vessels with an intramural segment (P = 0.003). Coronary CTA can identify an intramural segment of an anomalous interarterial coronary artery by its elliptical shape. Identifying an intramural segment has important clinical and surgical implications.

Origin of the right coronary artery from the opposite sinus of Valsalva in adults: Characterization by intravascular ultrasonography at baseline and after stent angioplasty

“…Several recent studies have recognized ACAOS as essentially the only type of CAA associated with intrinsic coronary stenosis that causes symptoms in adults, such as chest pain, syncope, and, less commonly, sudden cardiac arrest (SCA) or death (SCD) in the young . Both the right and left coronary arteries (RCA and LCA) can have ACAOS (R‐ACAOS and L‐ACAOS) . In our experience, ACAOSs angiographic prevalence is about 1.07% in cardiac catheterization laboratory patients , but it was about 0.7% in a large sample of schoolchildren who underwent screening by coronary magnetic resonance angiography for high‐risk cardiovascular conditions (hr‐CVC) to prevent SCD in the young ; we found ACAOS to be the most frequent hr‐CVC, comprising 40% of all hr‐CVCs, while the total prevalence of hr‐CVC was 1.6% .…”

Sports Behavior in Middle-Aged Individuals with Anomalous Coronary Artery from the Opposite Sinus of Valsalva

“…A virtual angiographic view was used for the evaluation of high-risk anatomic features such as a slit-like ostium [21, 22]. Double-oblique multiplanar reformatted images were used to identify other high-risk anatomic features such as acute-angle take-off, intramural course, elliptical course (defined as a height-to-width ratio of > 1.3), and proximal vessel narrowing of the anomalous vessels (> 50%) [21, 22]. ACAOS with IAC (between the aorta and pulmonary trunk) or a subpulmonary course (between the aorta and the right ventricular outflow tract) were classified as ACAOS with IAC (Fig.…”

Computed Tomography Imaging in Patients with Congenital Heart Disease Part I: Rationale and Utility. An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT)

“…118-120 Coronary CTA in patients of all ages with coronary anomalies is well described and has superior accuracy for this indication because of the ability to simultaneously visualize the coronary arteries as well as the great vessels. 117, 119,[121][122][123][124][125][126][127] CMR has been shown to be useful for congenital coronary anomalies in older children and adolescents, but is less useful in the youngest patients because image quality is 108,109 Thoracic Vasculature Abnormalities (Pulmonary/systemic venous abnormalities,…”