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Normal and Variant Coronary Arterial and Venous Anatomy on High-Resolution CT Angiography

¹ Present address: Quantum Medical Radiology, Atlanta, GA 30339.
² Department of Diagnostic Radiology, William Beaumont Hospital, 3601 W 13 Mile Rd., Royal Oak, MI 48073.
³ Present address: Elkhart General Healthcare System, Elkhart, IN 46514.

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —Anterior schematic diagram of heart shows course of dominant right coronary artery and its tributaries. AV = atrioventricular, PDA = posterior descending artery, RCA = right coronary artery, RV = right ventricular, SA = sinoatrial.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —CT images of normal heart in 53-year-old man. Ao = aortic root, CS = coronary sinus, LA = left atrium, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, LV = left ventricle, PDA = posterior descending artery, RA = right atrium, RCA = right coronary artery, RV = right ventricle, RVOT = right ventricular outflow tract. Axial 5-mm maximum-intensity-projection (MIP) image shows left main coronary artery as it arises from left coronary cusp.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —CT images of normal heart in 53-year-old man. Ao = aortic root, CS = coronary sinus, LA = left atrium, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, LV = left ventricle, PDA = posterior descending artery, RA = right atrium, RCA = right coronary artery, RV = right ventricle, RVOT = right ventricular outflow tract. Axial 5-mm MIP image shows right coronary artery as it arises from right coronary cusp inferior to level of beginning of left main coronary artery.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —CT images of normal heart in 53-year-old man. Ao = aortic root, CS = coronary sinus, LA = left atrium, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, LV = left ventricle, PDA = posterior descending artery, RA = right atrium, RCA = right coronary artery, RV = right ventricle, RVOT = right ventricular outflow tract. Axial 5-mm MIP image shows course of right coronary artery within anterior atrioventricular groove. Left anterior descending artery is shown within anterior interventricular groove, and left circumflex artery is shown in posterior atrioventricular groove.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —CT images of normal heart in 53-year-old man. Ao = aortic root, CS = coronary sinus, LA = left atrium, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, LV = left ventricle, PDA = posterior descending artery, RA = right atrium, RCA = right coronary artery, RV = right ventricle, RVOT = right ventricular outflow tract. Axial 5-mm MIP image shows origin of posterior descending artery from distal right coronary artery.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Conus branch anatomy variations. Ao = aortic root, LA = left atrium, LAD = left anterior descending artery, LM = left main coronary artery, LV = left ventricle, RA = right atrium, RCA = right coronary artery, RVOT = right ventricular outflow tract, SAN = sinoatrial node branch. Left anterior oblique 5-mm maximum-intensityprojection (MIP) image shows conus branch (arrow) in 44-year-old woman as it arises separate from right coronary artery off of right coronary cusp.

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Conus branch anatomy variations. Ao = aortic root, LA = left atrium, LAD = left anterior descending artery, LM = left main coronary artery, LV = left ventricle, RA = right atrium, RCA = right coronary artery, RVOT = right ventricular outflow tract, SAN = sinoatrial node branch. Left anterior oblique 15-mm MIP image shows common origin of conus branch (arrow) and right coronary artery in 40-year-old man.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —Conus branch anatomy variations. Ao = aortic root, LA = left atrium, LAD = left anterior descending artery, LM = left main coronary artery, LV = left ventricle, RA = right atrium, RCA = right coronary artery, RVOT = right ventricular outflow tract, SAN = sinoatrial node branch. Axial 10-mm MIP image shows conus branch (arrow) arising from proximal RCA in 52-year-old man. It then courses anteriorly toward right ventricular outflow tract.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D —Conus branch anatomy variations. Ao = aortic root, LA = left atrium, LAD = left anterior descending artery, LM = left main coronary artery, LV = left ventricle, RA = right atrium, RCA = right coronary artery, RVOT = right ventricular outflow tract, SAN = sinoatrial node branch. Axial 10-mm MIP image shows conus branch (arrow) arising from left anterior descending artery in 46-year-old man.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Sinoatrial node branch variations. Ao = aortic root, D1 = first diagonal, GCV = great cardiac vein, LA = left atrium, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, OM1 = first obtuse marginal, RCA = right coronary artery, RVOT = right ventricular outflow tract, SVC = superior vena cava. Axial 10-mm maximum-intensity-projection (MIP) image in 64-year-old man shows large sinoatrial node branch (arrow) as it arises from proximal right coronary artery. It then courses posteriorly toward cephalad aspect of interatrial septum (arrowheads) posterior to inflow of superior vena cava.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Sinoatrial node branch variations. Ao = aortic root, D1 = first diagonal, GCV = great cardiac vein, LA = left atrium, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, OM1 = first obtuse marginal, RCA = right coronary artery, RVOT = right ventricular outflow tract, SVC = superior vena cava. Axial 10-mm MIP image shows sinoatrial node branch (arrow) in 65-year-old woman as it arises from proximal left circumflex artery: Sinoatrial branch still courses toward cephalad aspect of interatrial septum.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Marginal branch anatomy. F = foot, LAD = left anterior descending artery, LV = left ventricle, RCA = right coronary artery, RV = right ventricle. Right anterior oblique 10-mm maximum-intensity-projection (MIP) image shows large marginal branch (arrow) arising from right coronary artery (RCA) in 40-year-old woman.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Marginal branch anatomy. F = foot, LAD = left anterior descending artery, LV = left ventricle, RCA = right coronary artery, RV = right ventricle. Right anterior oblique volume-rendered image shows marginal branch (arrow) of RCA as it courses over right ventricle in 45-year-old woman.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6 —Distal right coronary artery anatomy in 34-year-old man. Left anterior oblique 20-mm maximum-intensity-projection image shows course of entire right coronary artery. Distally, posterior descending artery and posterior lateral branch are shown, as is atrioventricular node branch. Ao = aortic root, AVN = atrioventricular node, IMB = inferior marginal branch, LCx = left circumflex artery, LV = left ventricle, PDA = posterior descending artery, PLB = posterior lateral branch, RCA = right coronary artery, RVOT = right ventricular outflow tract.

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —Distal dominant right coronary artery variation on axial projections. CS = coronary sinus, LV = left ventricle, MCV = middle cardiac vein, PDA = posterior descending artery, PLB = posterior lateral branch, PLV = posterolateral vein, RA = right atrium, RCA = right coronary artery, RV = right ventricle. Axial 10-mm maximum-intensity-projection (MIP) image in 51-year-old man shows typical tortuous course of posterior descending artery as it arises from distal right coronary artery. Posterior descending artery travels in inferior interventricular groove along side middle cardiac vein. Posterior lateral branch continues along distal coronary sinus to supply inferior wall.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —Distal dominant right coronary artery variation on axial projections. CS = coronary sinus, LV = left ventricle, MCV = middle cardiac vein, PDA = posterior descending artery, PLB = posterior lateral branch, PLV = posterolateral vein, RA = right atrium, RCA = right coronary artery, RV = right ventricle. Axial 10-mm MIP image shows dual posterior descending arteries and dual posterior lateral branches in 44-year-old man.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —Distal dominant right coronary artery variation on axial projections. CS = coronary sinus, LV = left ventricle, MCV = middle cardiac vein, PDA = posterior descending artery, PLB = posterior lateral branch, PLV = posterolateral vein, RA = right atrium, RCA = right coronary artery, RV = right ventricle. Axial 3D volume-rendered projection image shows origin of posterior descending artery, which still courses toward middle cardiac vein, is higher than normal in 49-year-old woman.

View larger version (181K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —Dominant left circumflex artery and posterior descending artery anatomy. Ao = aortic root, AVGA = atrioventricular groove artery, CS = coronary sinus, LA = left atrium, OM = obtuse marginal, PDA = posterior descending artery, PLB = posterior lateral branch, RA = right atrium, RCA = right coronary artery. Left anterior oblique 10-mm maximum-intensity-projection (MIP) images show two examples of dominant left circumflex artery anatomy with typical small nature of right coronary artery: one in 43-year-old woman (A) and one in 44-year-old man (B). Atrioventricular groove artery descends as larger-caliber artery in posterior atrioventricular groove subjacent to coronary sinus.

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —Dominant left circumflex artery and posterior descending artery anatomy. Ao = aortic root, AVGA = atrioventricular groove artery, CS = coronary sinus, LA = left atrium, OM = obtuse marginal, PDA = posterior descending artery, PLB = posterior lateral branch, RA = right atrium, RCA = right coronary artery. Left anterior oblique 10-mm maximum-intensity-projection (MIP) images show two examples of dominant left circumflex artery anatomy with typical small nature of right coronary artery: one in 43-year-old woman (A) and one in 44-year-old man (B). Atrioventricular groove artery descends as larger-caliber artery in posterior atrioventricular groove subjacent to coronary sinus.

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —Dominant left circumflex artery and posterior descending artery anatomy. Ao = aortic root, AVGA = atrioventricular groove artery, CS = coronary sinus, LA = left atrium, OM = obtuse marginal, PDA = posterior descending artery, PLB = posterior lateral branch, RA = right atrium, RCA = right coronary artery. Axial 10-mm MIP image shows dual posterior descending arteries as they arise from distal atrioventricular groove artery in 44-year-old man with dominant left circumflex artery.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —Codominance. Axial 10-mm maximum-intensity-projection image reveals codominant anatomy in which posterior descending artery arises from right coronary artery and posterior lateral branch arises from distal left circumflex artery in 33-year-old man. LV = left ventricle, PDA = posterior descending artery, PLB = posterior lateral branch, RCA = right coronary artery, RV = right ventricle.

View larger version (62K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10 —Dominant left coronary artery anatomy. Left anterior oblique schematic diagram of dominant left coronary artery anatomy, including left anterior descending artery and left circumflex artery tributaries, is shown. AVGA = atrioventricular groove artery, PDA = posterior descending artery.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11 —Left main coronary artery bifurcation. Anterior caudal 10-mm maximum-intensity-projection image displays typical bifurcation of left main coronary artery into left anterior descending and left circumflex arteries in 47-year-old man. AVGA = atrioventricular groove artery, D1 = first diagonal, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, OM1 = first obtuse marginal, SAN = sinoatrial node branch.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —Ramus intermedius anatomy. LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, RI = ramus intermedius artery. Right anterior oblique caudal 10-mm maximum-intensity-projection (MIP) image displays trifurcation of left main coronary artery into left anterior descending artery, ramus intermedius artery, and left circumflex artery in 49-year-old man.

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —Ramus intermedius anatomy. LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, RI = ramus intermedius artery. Axial 10-mm MIP image shows left main coronary artery dividing into left anterior descending artery, left circumflex artery, and ramus intermedius branches in 42-year-old woman.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12C —Ramus intermedius anatomy. LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, RI = ramus intermedius artery. Left posterior cranial 3D volume-rendered projection image shows branching ramus intermedius artery, which is mostly distributed as obtuse marginal branch to lateral wall, in 52-year-old man.

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13 —Left anterior descending artery course. Right anterior oblique 10-mm maximum-intensity-projection image reveals entire course of left anterior descending artery within anterior interventricular groove in 44-year-old woman. Distally, it is seen wrapping around left ventricular apex (arrows). LA = left atrium, LV = left ventricle.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14A —Myocardial bridge and septal perforator branch anatomy in 39-year-old woman. LA = left atrium, LAA = left atrial appendage, LV = left ventricle, S1, S2, S3 = first, second, and third septal perforators. Right anterior oblique 10-mm maximum-intensity-projection (MIP) image displays left anterior descending artery and septal perforator branches. Myocardial bridge overlies left anterior descending artery just beyond second septal perforator (arrows).

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14B —Myocardial bridge and septal perforator branch anatomy in 39-year-old woman. LA = left atrium, LAA = left atrial appendage, LV = left ventricle, S1, S2, S3 = first, second, and third septal perforators. Short-axis (left anterior oblique) 5-mm MIP image at level of myocardial bridge shows left anterior descending artery (arrow) deep to right ventricular myocardium junction with left ventricle.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15A —Diagonal branch anatomy. D1 = first diagonal, D2 = second diagonal, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, LV = left ventricle, RI = ramus intermedius artery, SP = septal perforator branches. Axial caudal oblique 10-mm maximum-intensity-projection (MIP) image reveals two diagonal branches (D1 and D2) from left anterior descending artery in 55-year-old man. Diagonal branches course laterally, and small septal perforator branches course medially.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15B —Diagonal branch anatomy. D1 = first diagonal, D2 = second diagonal, LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, LV = left ventricle, RI = ramus intermedius artery, SP = septal perforator branches. Cranial left anterior oblique 10-mm MIP image shows left anterior descending artery and two diagonal branches in 47-year-old man.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16A —Nondominant left circumflex artery anatomy in 36-year-old man. AVGA = atrioventricular groove artery, CS = coronary sinus, D1 = first diagonal, GCV = great cardiac vein, LAD = left anterior descending artery, LCx = left circumflex artery, OM1 = first obtuse marginal. Axial 10-mm maximum-intensity-projection (MIP) image shows left circumflex artery and left anterior descending artery with large first obtuse marginal arising from proximal left circumflex artery. Small left circumflex artery descends in posterior atrioventricular groove as atrioventricular groove artery.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16B —Nondominant left circumflex artery anatomy in 36-year-old man. AVGA = atrioventricular groove artery, CS = coronary sinus, D1 = first diagonal, GCV = great cardiac vein, LAD = left anterior descending artery, LCx = left circumflex artery, OM1 = first obtuse marginal. Left anterior oblique 10-mm MIP image displays left circumflex artery anatomy with its descent as atrioventricular groove artery.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17A —Dominant left circumflex artery anatomy in 44-year-old man. AVGA = atrioventricular groove artery, LCx = left circumflex artery, LM = left main coronary artery, OM1 = first obtuse marginal, OM2 = second obtuse marginal, PDA = posterior descending artery, PLB = posterior lateral branch, RI = ramus intermedius artery. Left anterior oblique cranial 3D volume-rendered image shows dominant left circumflex artery anatomy with two obtuse marginal branches.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17B —Dominant left circumflex artery anatomy in 44-year-old man. AVGA = atrioventricular groove artery, LCx = left circumflex artery, LM = left main coronary artery, OM1 = first obtuse marginal, OM2 = second obtuse marginal, PDA = posterior descending artery, PLB = posterior lateral branch, RI = ramus intermedius artery. Axial 3D volume-rendered image reveals dual posterior descending artery and posterior lateral branch arising from distal atrioventricular groove artery.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18A —Anomalous origin of right coronary artery and left main coronary artery. Ao = aortic root, LAD = left anterior descending artery, LM = left main coronary artery, RCA = right coronary artery, RVOT = right ventricular outflow tract. Axial 5-mm maximum-intensity-projection (MIP) image shows anomalous origin of right coronary artery in 43-year-old woman from anterior proximal ascending aorta with subsequent acute rightward course before reaching anterior atrioventricular groove.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18B —Anomalous origin of right coronary artery and left main coronary artery. Ao = aortic root, LAD = left anterior descending artery, LM = left main coronary artery, RCA = right coronary artery, RVOT = right ventricular outflow tract. Three-dimensional volume-rendered projection image shows anomalous right coronary artery in same patient as A above level of right coronary cusp (arrow).

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18C —Anomalous origin of right coronary artery and left main coronary artery. Ao = aortic root, LAD = left anterior descending artery, LM = left main coronary artery, RCA = right coronary artery, RVOT = right ventricular outflow tract. Axial 10-mm MIP image reveals anomalous origin of left main coronary artery in 35-year-old man from right cusp near origin of right coronary artery. It then takes intraseptal course posterior to right ventricular outflow tract near cephalad aspect of interventricular septum.

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