Cardiac Imaging: Part 2, Normal, Variant, and Anomalous Configurations of the Coronary Vasculature
Abstract
OBJECTIVE. Noninvasive imaging of the heart and coronary vasculature using CT and MRI is a new and exciting opportunity for radiologists. The purpose of this pictorial essay is to review normal and variant anatomy of the coronary arteries and of several coronary anomalies that may be clinically significant. The coronary veins and artifacts simulating disease will also be briefly covered. This article will help radiologists learn and review normal coronary anatomy, normal variants, and coronary anomalies and recognize pitfalls, such as coronary veins and artifacts, that may be confusing when first encountered.
CONCLUSION. The coronary arteries generally are predictable in their origin, course, and perfusion territories. Standardized reporting systems exist for describing the location of specific lesions, and radiologists who interpret CT and MR coronary images should be aware of and should attempt to integrate these reporting schemes into clinical practice.
Advances in temporal and spatial resolution in MDCT and MRI have led to new clinical applications in imaging the coronary vasculature. The expanding role of these modalities in noninvasively detecting or excluding coronary stenosis represents a new opportunity for radiologists, and use of the technology has greatly increased in recent years. However, many radiologists have had little training in coronary imaging and may not be familiar with coronary anatomy. Additionally, the increasing use of CT and MRI for noninvasive cardiac imaging also will expose radiologists more frequently to relatively rare anomalous and variant configurations of the coronary vasculature, some of which are associated with an increased risk of sudden cardiac death. This article will review normal, variant, and anomalous coronary artery vascular segmental anatomy.
Basics of Coronary Embryology
Although describing the coronary anatomy of most patients is straightforward, it is important to note that the coronary arteries are named for the structures that they supply rather than for their origin. This nomenclature is based on fundamental embryologic principles; the coronary stems arise within the developing myocardium and only later attach to their blood supply from the aorta [1] (Fig. 1). The various perturbations in the connections of the coronaries to each other and to their aortic supply occur subsequent to the formation of the coronary stems in the myocardium. The distinction between a variant coronary pattern and a potentially dangerous anomaly is therefore typically based on the potential clinical implications rather than on the embryologic cause.
Normal Coronary Anatomy
The coronary tree and, in particular, the major branches of the coronary arteries are named according to their appearance on angiograms rather than on axial images. The nomenclature of the coronary branches makes sense when keeping in mind the appearance of the heart on a left anterior oblique (LAO) view (Fig. 1).
The reporting scheme for coronary segments presented here is based on that presented in an American Heart Association (AHA) ad hoc committee report [2] and adapted for cross-sectional imaging in a Society of Cardiovascular Computed Tomography report [3] because of its relative simplicity and straightforward translation to cross-sectional imaging (Fig. 2). Other commonly used angiographic schemes are similar, also having been adapted from the original AHA report [4, 5]. Adherence to established schemes is essential both to ensure standardization and reproducibility of results and to gain the confidence of referring physicians.
The coronary veins have historically received less attention than the coronary arteries. They often course alongside the coronary arteries, and it is important not to confuse one for the other. Defining the coronary venous anatomy may also be important in cases of coronary fistula or arteriovenous malformation (AVM) or may be useful before certain electrophysiologic procedures.
Right Coronary Artery of the Heart
Definition—The right coronary artery (RCA) is defined as the artery that supplies the morphologic right ventricle. It typically arises from the right sinus of Valsalva (Fig. 3) and travels in the right atrioventricular groove (Fig. 4) toward the “acute margin” of the heart. The RCA is best seen on an LAO view of the heart, as would be obtained during cardiac catheterization, in which the lateral margin of the right ventricle appears to form an acute angle. The tip of the angle is called the acute margin. When the RCA reaches the acute margin, it turns to continue between the right atrium and right ventricle at the base until it reaches the junction with the atrial and ventricular septa.
The RCA is divided into proximal, middle, and distal segments. The proximal segment is from the origin halfway to the acute margin. The middle segment is from this halfway point to the acute margin itself. The distal segment is from the acute margin to the base of the heart at the junction of the atrial and ventricular septa (Fig. 5).
Right coronary artery branches—In 50–60% of individuals, a conus branch arises as the first branch of the RCA to supply the right ventricular outflow tract. The conus branch can serve as an important source of collateral supply to the left anterior descending (LAD) artery through the so-called “circle of Vieussens” in select cases of severe left main coronary artery (LMCA) or proximal LAD coronary disease.
The right ventricular free wall is supplied through acute marginal branches of the RCA. Typically, the halfway point between the RCA ostium and the acute margin of the right heart border—the dividing point between the proximal and middle RCA segments—is marked by the origin of a large acute marginal branch. This branch can serve as a useful marker for dividing the proximal segment from the middle segment on axial images (Fig. 5).
Other branches that may be present include the sinoatrial nodal branch, arising from the proximal RCA in 60% of people [6], and the atrioventricular nodal branches, arising from a U-shaped crux cordis at the base of the heart in 90% of people.
Left Main Coronary Artery
The LMCA typically arises from the left sinus of Valsalva. The LMCA typically does not have significant branches of its own but quickly bifurcates into the LAD and circumflex coronary arteries (Fig. 6).
Left Anterior Descending Artery
The LAD artery arises from the bifurcation of the left coronary artery (LCA) and travels in the epicardial fat along the anterior interventricular groove between the right and left ventricles. On the LAO view of the heart, the LAD artery can be seen appearing to “descend” nearly vertically, giving off diagonal branches to the anterior left ventricular wall. In addition to supplying the anterior wall, the LAD artery also gives off septal perforator branches that supply the anterior two thirds of the basal interventricular septum and the entire septum at the mid and apical levels.
Like the RCA, the LAD artery is divided into three segments (Fig. 7). The proximal segment runs from the LAD origin to the origin of the first septal perforator. The middle segment runs from the first septal perforator origin halfway to the left ventricular apex. The distal segment runs from this halfway point to the apex itself.
Circumflex Artery
The left circumflex (LCX) artery arises from the LCA bifurcation and travels in the left atrioventricular groove, supplying the lateral wall of the left ventricle and variable portions of the inferior wall through the obtuse marginal and posterolateral branches, respectively.
Unlike the RCA and LAD artery, the LCX artery has only two segments (Fig. 8). The proximal segment runs from the LCX origin to the origin of the first obtuse marginal branch. The distal segment includes everything distal to this origin. In some patients, a posterolateral branch arises from the LCX artery or an obtuse marginal branch to supply a portion of the inferior wall. The LCX artery may also supply branches to the atrioventricular node.
Posterior Descending Artery
The posterior descending artery (PDA) runs in the posterior interventricular groove between the right and left ventricles and supplies the inferior wall and inferior one third of the interventricular septum. The PDA can arise from the distal RCA (70%) or distal LCX artery (10%) or can receive elements from both (20%).
Coronary Dominance
Because of the variability in arterial supply to the inferior wall, the concept of coronary dominance is important to understand. In fact, most cardiac catheterization and coronary CT reports should begin with a statement of coronary dominance. Various definitions of coronary dominance have been proposed, but understanding the supply to the inferior wall and atrioventricular node is the most important concept. The most accurate definition of dominance would refer to the arterial supply to the atrioventricular node. However, the node itself is not directly visualized on CT, and the artery that supplies the atrioventricular nodal branches in the crux cordis typically supplies the inferior wall through the PDA as well.
For our purposes, a right-dominant system will be considered one in which the PDA and a posterolateral branch arise from the distal RCA. A left-dominant system is one in which the PDA and posterolateral branch arise from the distal circumflex artery. A codominant system is one in which the PDA arises from the distal RCA and a posterolateral branch arises from the distal circumflex to supply some of the inferior wall or one in which there are two PDA branches, one from the RCA and one from the LCX artery (Figs. 9 and 10). Approximately 70% of individuals have a right-dominant system, whereas 20% have a codominant system and 10%, a left-dominant system.
Coronary Veins
The coronary veins run in the interventricular and atrioventricular grooves with the coronary arteries and are well seen on CT [7–9]. They may also be important to delineate before surgery or intervention for a coronary artery fistula or AVM, and some investigators have advocated using CT to visualize the coronary veins before electrophysiology procedures [10].
The anterior interventricular vein runs along with the LAD artery in the anterior interventricular groove from the apex of the heart toward the base (Fig. 11). Once the anterior interventricular vein reaches the LAD bifurcation, it turns to descend in the left atrioventricular groove with the circumflex coronary artery as the great cardiac vein (Fig. 12). As the great cardiac vein descends the atrioventricular groove, the great cardiac vein receives small tributaries (typically including a left marginal vein from the lateral wall or a left posterior vein draining the inferolateral wall) before joining the coronary sinus at the base of the heart (Fig. 13). A small vein draining the left atrium—that is, the vein of Marshall, an embryologic remnant of the left superior vena cava—can often be found draining into the coronary sinus as well, and the point at which it enters the coronary sinus is anatomically the dividing line between the great cardiac vein and the coronary sinus. The coronary sinus also receives the middle cardiac vein, which runs in the posterior interventricular groove with the PDA (Fig. 13). The appropriately named small cardiac vein usually drains directly into the right atrium, as anterior cardiac veins draining the right ventricle, next to the proximal RCA in the right atrioventricular groove.
Normal Variants
Inferior Wall Supply
As we noted earlier, the origin of the PDA is variable. In fact, the vascular supply to the inferior wall may be thought of as a spectrum of variants. Some individuals have a very small PDA and instead have multiple branches from the distal RCA, LCX, and obtuse marginal branches supplying the inferior wall (Fig. 14). Other patients have early takeoff of the PDA, which then courses toward the apex along the diaphragmatic surface of the right ventricle. In another variant, the LAD wraps around the apex to supply some of the apical inferior wall; this variant is known as the “wraparound LAD.” In addition to being a normal anatomic variant, the wraparound LAD can lead to a “mirror image” artifact on centerline vessel trace algorithms (Fig. 15).
Atrioventricular Nodal Supply
Typically, the dominant artery that supplies the PDA and inferior wall gives rise to a U-shaped crux at the base of the heart that, in turn, gives off small branches that supply the atrioventricular node. The atrioventricular node is a small bundle of tissue located at the center of the Koch triangle—a triangle enclosed by the septal leaflet of the tricuspid valve, the coronary sinus, and the membranous part of the interatrial septum. This tissue is important to the electrophysiologic activity of the heart because it delays conduction of the electric impulse from the atria to the ventricles, allowing time for the additional ventricular preload caused by atrial contraction. Because right dominance is more common, these branches typically arise from the distal RCA.
Sinoatrial Nodal Supply
The sinoatrial node, another electrically active bundle of tissue, sits near the junction of the upper right atrium and the superior vena cava. It acts as the primary pacemaker in normal sinus rhythm and is supplied by a single sinoatrial nodal branch from the proximal RCA in 60% of people [6]; however, the sinoatrial nodal branch can also arise from the proximal LCX artery or even the distal RCA or LCX artery in unusual circumstances.
Ramus Intermedius
In some patients, rather than bifurcating into an LAD artery and LCX artery, the LCA trifurcates into an LAD artery, an LCX artery, and a ramus intermedius (Fig. 16). The ramus intermedius typically acts to supply the lateral and inferior walls in the manner of diagonal or obtuse marginal branches. The arteries that typically would supply that territory are diminutive or nonexistent presumably because the vessels supplying that portion of the myocardium have coalesced into the ramus intermedius rather than into their typical pattern.
Right Superior Septal Perforator
The right superior septal perforator is a variant occurring in approximately 3% of patients who undergo coronary angiography [11]. Like the septal perforators arising from the proximal LAD artery, the right superior septal perforator supplies the anterior septum but arises from the proximal RCA or the right sinus of Valsalva. Like the conus branch, the right superior septal perforator may serve as a potential source of collateral supply to the LAD artery with LCA or proximal LAD disease.
Supernumerary Coronary Ostia
In addition to the typical RCA and LCA origins from the aorta, some patients have smaller branches that arise directly from the aorta rather than arising as branches from the coronary arteries. Among the more common variants are separate origins of the LAD and LCX arteries from the left coronary sinus with no common LMCA and a separate origin of the conus branch directly from the aorta rather than from the proximal RCA (Fig. 17). Although these anomalies could potentially have clinical consequences if unrecognized during surgery or coronary catheterization, they are not clinically significant in most people.
Myocardial Bridging
Normally, the coronary arteries travel in the epicardial fat along the surface of the heart as they cross their perfusion territories. In some individuals, however, the coronary artery “dives” from the epicardial fat into the myocardium for variable lengths (Fig. 18). This configuration leaves a segment of bridging myocardium superficial to the coronary artery and typically occurs in the middle segment of the LAD artery but can occur in other segments as well. Although angiography may show up to 50% systolic narrowing of the affected artery, these findings are very rarely clinically significant at least in part because most coronary blood flow occurs in diastole (when the myocardium is relaxed and requires less pressure for perfusion). Interestingly, the bridged coronary segment is frequently spared of atherosclerotic disease [12]. The typically benign prognosis of these variants is underscored by the results of an 11-year follow-up study [13] of 61 patients with bridged coronary segments incidentally discovered during coronary angiography; in that study population, no patients developed myocardial ischemia and outcomes did not correlate with the degree of systolic compression seen during angiography [13]. Angiography may, in fact, significantly underestimate the prevalence of myocardial bridging: Recent articles have shown bridging on CT in nearly a third of patients at low risk of ischemic heart disease [14, 15]. The term “tunneling” rather than “bridging” may be used to signify the likely benign prognosis of most cases.
As with any finding, however, the clinical significance should be interpreted only in conjunction with the remaining scanning results and the clinical situation. Myocardial bridging may rarely cause limitation of flow, particularly if the segment is long or deep, is associated with coexistent stenoses, or is supplying a collateralized territory. Atypical angina may be the presenting symptom in such patients [16].
Coronary Anomalies
Coronary artery anomalies are fairly common, occurring in 0.3–1.3% of patients at angiography and 0.3–0.5% at autopsy [17–19]. Some of the variability in the reported incidence likely reflects referral bias and even variability in definitions of “anomalous” and “normal” variant.
Ectopic Coronary Origin From the Contralateral Coronary Sinus
Ectopic coronary origin is the most frequently encountered coronary anomaly and is particularly important to recognize because some forms can be associated with angina and an increased risk of sudden cardiac death. The most common of these coronary anomalies is ectopic origin of a coronary artery from the coronary sinus opposite its normal perfusion territory. As many as 26% involve some sort of aortic root abnormality, such as bicuspid aortic valves. In general, the origin of the ectopic coronary artery is not problematic, but the course that the abnormal coronary artery takes to its perfusion territory can have important consequences.
Conceptually, a coronary artery that arises from the contralateral sinus of Valsalva has four potential paths it may take to its perfusion territory: prepulmonic (anterior to the right ventricular outflow tract), retroaortic (posterior to the aortic root), septal (through the proximal interventricular septum, analogous to a right superior septal perforator), or interarterial (between the aorta and pulmonary artery) (Figs. 19, 20, 21, and 22). The former two scenarios (i.e., prepulmonic and retroaortic) are considered benign coronary anomalies, putting the patient at little risk of an adverse event. An interarterial course of an anomalous coronary artery, however, is associated with an increased risk of sudden cardiac death for reasons that are still not entirely clear. The risk of sudden death may be as high as 30% [20], and anomalous coronary arteries have been implicated as the cause of 5–35% of sudden deaths in young athletes [21]. Most deaths attributed to coronary anomalies occur in young individuals during vigorous exercise. The risk of sudden death in a middle-aged or elderly individual with an incidentally discovered anomaly is unclear but is probably lower than the risk of sudden death in a younger patient.
The most frequently cited hypothesis for the cause of sudden death is that angulation of the anomalous vessel can cause a valve-like ostial ridge. In addition, some interarterial coronaries actually take an intramural course through the wall of the aorta, which may cause them to be compressed during aortic pulsation (Fig. 21). Either of these mechanisms may limit inflow. A series of 32 necropsies of patients with interarterial coronaries originating from the contralateral coronary sinus did not establish a statistically significant outcome difference in patients with a slitlike ostial morphology but did note an association between negative outcomes and dominance of the anomalous coronary artery [22].
Although the precise mechanism of death is unclear, patients with interarterial coronaries (particularly young, active patients) are at risk of sudden death. Patients who are incidentally discovered to have these anomalies often empirically undergo coronary bypass surgery. However, given the rarity of coronary anomalies, optimal management of these patients has not yet been established. For example, no outcomes data support the notion that coronary bypass grafting decreases the risk of sudden cardiac death in this population. There is some evidence that anomalous RCAs with an interarterial course are associated with a more benign prognosis than interarterial LCAs. In our practice, some patients with interarterial RCAs undergo some form of stress testing before determination of an operative course.
Some anomalous interarterial coronary arteries are known to take an intramural course— that is, tunneling through the wall of the aorta. Whether this course places the patient at additional risk of sudden cardiac death is unclear but it does offer a surgical option for the correction of this anomaly of unroofing rather than bypass [23]. Our experience has been that when using the most up-to-date CT scanners (in our institutions, dual-source CT scanners), CT can predict with good accuracy which arteries have an intramural course (Fig. 21).
Radiologic reporting of these cases should clearly include the origin of each coronary artery, the path of the abnormal coronary artery to its perfusion territory, and the overall coronary dominance pattern. Additional tortuosity, marked angulation, and coexistent atherosclerosis should be noted as well as any objective evidence of downstream myocardial ischemia or infarction, such as myocardial thinning or hypoattenuation of the subendocardial myocardium.
We should also note that nongated chest CT studies may have pulsation artifacts that can mimic interarterial coronary arteries. Between 6% and 20% of patients thought to have interarterial course on ungated chest CT have been shown to have normal coronary origins on gated cardiac CT, MRI, or selective angiography. Some of the variation in the positive predictive values of ungated CT probably relates to the detector number and temporal resolution of the scanner in use [24, 25] (Fig. 23).
Bland-White-Garland Syndrome
An anomalous LCA arising from the pulmonary artery, known by the eponym of Bland-White-Garland syndrome, usually presents in infants or children. In very young patients, the presenting symptoms of Bland-White-Garland syndrome are usually those of myocardial ischemia due to coronary steal phenomenon. In older patients whose bodies presumably have compensated for the steal with collateralized vessels, progressive left-to-right shunting may develop. The physiology of left-to-right shunting is similar to that of coronary fistulas and AVMs (discussed later) and patients with left-to-right shunting can present with pulmonary hypertension. Imaging findings in these patients can be striking, with markedly dilated collateral arteries and coronary veins [26].
Coronary Aneurysms
Coronary aneurysms may result from many causes, including inflammatory disorders such as Kawasaki disease, connective tissue disorders, or iatrogenic complications of surgery or catheterization; however, the most common cause is atherosclerosis [27] (Fig. 24). Coronary aneurysms are uncommon, occurring in roughly 1.5% of autopsies [28]. The prognosis associated with coronary aneurysms is often uncertain both because relatively few cases have been followed and because the prognosis likely varies according to the underlying cause. Complications are similar to those of aneurysms in other areas of the body, including rupture, thrombosis, and distal embolization. Coronary aneurysms are most often incidentally discovered, and management is controversial.
Coronary Fistulas and Arteriovenous Malformations
Unfortunately, there is not a clear distinction between discrete coronary fistulas, which are comparatively common, and complex coronary AVMs in the medical literature. Collectively, they have been described in as many as 0.5% of coronary angiograms [29]. Historically, coronary fistulas and AVMs are the most common indications for surgical repair of a coronary artery anomaly.
Coronary fistulas and AVMs usually have a benign clinical course, but patients can present with symptoms resulting from left-to-right shunting, such as pulmonary hypertension. Coronary steal phenomenon may also occur, leading to ischemia and, only very rarely, to infarction. In one study of 51 patients with coronary steal phenomenon (mean age, 60 years) [30], the 5-year mortality was only 4%. Thirteen patients had angina pectoris without significant coronary atherosclerosis, and seven had objective evidence of coronary insufficiency [30]. In some cases, severe symptoms and striking imaging findings may be present, and imaging can be key in helping to outline the anatomy and plan treatment (Fig. 25). If suspected or incidentally found, coronary AVMs should be imaged up to the aortic arch because they may have significant bronchial contributions, which could be important to know if surgical intervention is planned.
Conclusion
The coronary arteries generally are predictable in their origin, course, and perfusion territories. Standardized reporting systems exist for describing the location of specific lesions, and radiologists who interpret CT and MR coronary images should be aware of and should attempt to integrate these reporting schemes into their clinical practices. Coronary variants and anomalies are commonly encountered and sometimes can be clinically relevant. Familiarity of radiologists with the more commonly encountered anomalies, such as origin of a coronary artery from the contralateral coronary sinus, will become increasingly important as cardiac imaging volumes with CT and MR continue to increase.

























Footnote
CME SAM Cardiac Imaging
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Submitted: March 8, 2010
Accepted: May 30, 2010
First published: November 20, 2012
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