Abstract
The high take-off of the coronary artery is rarely encountered in the catheterization laboratory. But the origin of a single coronary artery with high take-off makes it even more rare. The high take-off of a single coronary artery may have an association with coronary artery disease, as in this case. In the present case, a 55-year-old male underwent a coronary angiogram, but coronaries could not be cannulated despite multiple catheter usage. Then, computed tomography was performed which revealed high take-off of single coronary artery and had triple vessel disease, for which coronary artery bypass surgery was performed successfully.
< Learning objective: Difficulty or inability of cannulation of coronary arteries on angiography should have a suspicion of anomalous origin of coronary arteries. Computed tomography is the investigation of choice for identifying the anomalous origin of the coronary artery and its course, as conventional coronary angiogram may not depict an abnormal course of the coronary artery, which may be clinically significant.>
Introduction
Coronary artery anomaly poses major diagnostic and therapeutic challenges. It may be benign or malignant in a clinical course. The prevalence of high take-off coronary arteries in the general population is 0.20% . It can be associated with sudden cardiac death . Computed tomography is the investigation of choice for a thorough evaluation of coronary artery anomalies especially when coronary angiography is not possible by catheterization . It is uncommon to find a single coronary artery arising from tubular aorta, as in the present case.
Case report
A 55-year-old man, non-diabetic, but hypertensive presented with sudden onset chest pain with perspiration. He was diagnosed as having an acute anterior and inferior wall myocardial infarction for which he was thrombolyzed with reteplase. He came to our institute for a coronary angiogram. We tried coronary angiogram in the catheterization laboratory using multiple catheters including JL 3.0, JL 3.5, JR 3.0, AL 1,2, and AR catheter but coronaries could not be cannulated. An aortogram was also taken which was not conclusive but gave a clue for anomalous origin of coronary arteries.
Then computed tomography was performed which confirmed the anomalous origin of coronary arteries. It showed a single coronary artery trunk arising from an anomalous high location at tubular part of ascending aorta 10 mm above sinotubular junction which is commonly termed as high take-off coronary artery ( Fig. 1 A, B, and C). The left circumflex artery also had a fibrotic plaque-causing short segment, near-total occlusion near ostium ( Fig. 1 D and E). The right coronary artery was dominant and ran between the aortic root and pulmonary trunk (inter arterial course) with mild compression ( Fig. 1 F and G). The proximal right coronary artery was completely occluded involving 16 mm of its length ( Fig. 1 A, F, G). There was near-occlusion of the mid-left anterior descending artery (LAD) with a fibrocalcific plaque of 28 mm in length, while distal LAD had less than 50% stenosis ( Fig. 1 C, H). The first diagonal branch had 50–60% stenosis with eccentric plaque ( Fig. 1 C). For this, he underwent coronary artery bypass surgery with left internal mammary artery to left anterior descending artery, right saphenous venous graft to ramus intermedius, right saphenous venous graft to obtuse marginal branch, and right saphenous venous graft to right coronary artery. He had a smooth postoperative recovery and was discharged in stable condition. Informed consent has been taken from the patient for this case report.
