J Lipid Atheroscler.  2015 Dec;4(2):131-135. 10.12997/jla.2015.4.2.131.

Missing Right Coronary Artery in a Patient with Acute Inferior ST Segment Elevation Myocardial Infarction: A Case of Extremely Rare Variation of Coronary Anatomy

• Lee JH
• Suh Y
• Yoon IC
• Jung YH
• Choi SH
• Cho YH
• Cho DK

• KMID: 2151821
• DOI: http://doi.org/10.12997/jla.2015.4.2.131

Abstract

We recently encountered an interesting case of acute inferior ST segment elevation myocardial infarction (STEMI). This patient had a rare anatomic variation, single coronary artery. The right coronary artery originate from the left circumflex proper artery, not from aorta, was totally obstructed with thrombi. Though it took more time to figure out the patient's coronary anatomy and the culprit lesion, we successfully performed primary percutaneous coronary intervention within the guideline-recommended time period. We performed left coronary angiography at the beginning. This strategy could be helpful in determining the culprit lesion and preventing unnecessary procedural delay in acute inferior STEMI.

Keyword

Coronary vessel anomalies; Myocardial infarction; Percutaneous coronary intervention

MeSH Terms

Anatomic Variation
Aorta
Arteries
Coronary Angiography
Coronary Vessel Anomalies
Coronary Vessels*
Humans
Myocardial Infarction*
Percutaneous Coronary Intervention

Figure

• 

  Fig. 1. Electrocardiography (ECG) on arrival and one day after the procedure. (A) The initial ECG showed ST segment elevations in leads II, III, and aVF, while reciprocal ST depressions were detected in leads V2-5. The ST segment in lead I is depressed, and the ST ratio II/III is less than 1. This finding strongly suggests that the culprit lesions were in the right coronary artery (RCA) rather than in the left circumflex (LCX) artery in right dominant coronary system, (B) ST segment elevation was fully recovered one day after the procedure.

• 

  Fig. 2. Coronary angiography before revascularization. (A) Left coronary angiography showed totally occluded LCX proper artery and an intermediate lesion in the mid-segment of left anterior descending artery, (B) Aortography did not show any ostium of RCA in the aorta.

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  Fig. 3. Coronary angiography after revascularization. (A) After conducting balloon angioplasty for the LCx proper artery, the missing RCA was found in the distal to LCx proper artery, (B) After stent insertion, the coronary angiography showed that the RCA originated from the LCx proper artery and extended into the right ventricular area, tapering towards the distal part.

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  Fig. 4. Followed computed tomography coronary angiography 3 months after procedure confirmed that the RCA originated from distal LCX proper artery.

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