Double Right Coronary Artery with Atherosclerosis: A Rare Coronary Artery Anomaly

There is considerable variety in size and position of the coronary arteries.1 The incidence of coronary anomaly in one of the largest series (126,595 cases) was reported to range between 0.6–1.3%.2 The majority of these were reported to be anomalies of origin or distribution, with separate ostia of the left anterior descending artery and left circumflex artery being the most common.2 We present a very rare coronary artery anomaly, a double right coronary artery (RCA). To the best of our knowledge, this is the third well-established case in the literature.3,4 However, this is the first case in which both right coronary arteries are diseased. If this anomaly had gone undiagnosed, the patient’s symptoms would have recurred despite revascularization. Case Report. A 54-year-old male patient was hospitalized with the diagnosis of unstable angina pectoris. He had a long-lasting severe chest pain 5 days before admission. He had diabetes in addition to hyperlipidemia. The electrocardiogram at admission revealed T-wave inversion in the inferolateral leads with elevation of creatine kinase, its isoform creatine kinase MB (576/77 IU/L) and troponin T (> 2 ng/ml). On the third day of his admission, a coronary angiogram was performed that revealed multiple severe stenoses in the left coronary artery including the anterior descending and circumflex artery and its branches. The RCA was selectively cannulated with a 6 French Judkins right diagnostic catheter. The injection revealed a small caliber artery with mild to moderate stenosis (Figure 1). Since the pressure wave was dampened and the contrast did not flush, the catheter was withdrawn immediately. During withdrawal, contrast stealing was observed to fill another artery just beneath the previously cannulated RCA (Figure 2). We then selectively intubated the second artery and observed a second RCA with a severe stenosis and an aneurysmal dilation in its mid portion (Figure 3). Repeated injection after slight withdrawal of the catheter revealed opacification of the second RCA originating proximal to the catheter ostium, giving the sense of a separate or very short common ostium (Figure 4). Because of multivessel involvement, coronary artery bypass graft surgery was planned. Discussion. Most anomalies are discovered as incidental findings during coronary angiography. The first report in the literature was by Barthe et al.3 The authors defined this anomaly after injecting the contrast into the right coronary orifice, which disclosed selective opacification of two different right coronary arteries arising from a common ostium, coursing down the right atrioventricular groove. At surgery for aortic stenosis, the presence of a single right coronary ostium was confirmed.3 Aydogdu et al. reported the second well-defined case.4 The authors presented a case with two right coronary arteries with different sizes during right coronary sinus injection, a large-caliber posteriorly located vessel and a smaller anteriorly located vessel. These two previously reported cases of double right coronary arteries were both disease free.3,4 However, we observed atherosclerotic narrowing in both right coronary arteries. Besides, in these two previous cases, the authors spontaneously and simultaneously opacified both right coronary arteries in their first injection after engagement of the right coronary ostium, most probably due to some form of longer common ostium to both right coronary arteries. However, it was just incidental in our case. We believe that every operator should be familiar with this kind of rare anomaly to prevent an inadequate examination leading to subsequent errors in management. Failure to recognize such an anomaly with atherosclerotic arterial involvement could have been quite troublesome after bypass surgery, leading to inadequate revascularization. The problem with this case is the presence of 2 separate or one very short common ostium to 2 right coronary arteries. This could have prevented the spillover of the contrast to the other artery, making it difficult to diagnose. This case could have easily gone undiagnosed if the withdrawal of the artery hadn’t been performed during cine acquisition, which disclosed stealing of contrast by the adjacent RCA. The other point is that since both RCAs were equally dominant, there was no reason to look for an additional RCA. Besides, deep intubation of the ostium could also be another potential factor, which may lead to obstruction of the proximally arising second RCA. Obviously, these reasons could be the cause of the rarity of this anomaly. Barthe et al. showed that careful examination of the left ventriculogram might disclose 2 retroaortic points, suggesting the presence of a double RCA.3 However, withdrawing the catheter during cine acquisition just before the end of the coronary imaging might also be helpful for detecting these kinds of anomalies as in our case. This maneuver may especially be helpful in case of deep intubation of the coronary ostium by providing contrast steal by the obstructed artery during withdrawal.

1. Angelini P, Villason S, Chan AV, et al. Normal and anomalous coronary arteries in humans. In: Angelini P (ed). Coronary Artery Anomalies: A Comprehensive Approach. Philadelphia: Lippincott Williams & Wilkins, 1999: pp. 27. 2. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28. 3. Barthe JE, Benito M, Sala J, et al. Double right coronary artery. Am J Cardiol 1994;73:622. 4. Aydogdu S, Özdemir M, Diker E, et al. Double right coronary artery. A rare coronary artery anomaly. Acta Cardiol 1997;52:359–361.