**6. Angiographic diagnosis of ectopic vessels and courses**

#### **6.1 Angiographic diagnosis of ectopic vessels**

The diagnosis of ANOCOR in adult patients is usually suspected or achieved during a selective coronary angiography scheduled to evaluate or to rule out a CAD. The invasive coronary angiography is no longer considered the method of choice, in other terms *the gold standard*, for an accurate diagnosis of ANOCOR. Studies have described the correlations between invasive angiography and CT angiography but always in small populations. Correct identification of the ectopic vessel was achieved by conventional angiography in 69% (9/13) of ANOCOR (Shi et al., 2004). Selective catheterization and precise vessel determination was possible in only 53% (8/15) of ANOCOR (Schmitt et al., 2005). The coronary abnormality was accurately depicted in 44% (4/9) of ANOCOR (de Jonge et al., 2008). Several shortcomings of the conventional angiography are obvious, such as a difficult canulation of the abnormal orifice, a two-dimensional interpretation of the ectopic course, or

Proximal Anomalous Connections of Coronary Arteries in Adults 201

The ectopic orifice of the left coronary artery (LMCA, LAD coronary artery or CX coronary artery) is in most cases very close to the right coronary orifice, and sometimes contiguous. Thus, a selective angiography is generally easier using Judkins right catheter or Amplatz left or right catheters. A multipurpose catheter may be useful to catheterize the orifice of an

**6.1.2 Angiographic diagnosis of anomalous connection with the contralateral artery** 

**6.1.3 Angiographic diagnosis of anomalous connection with the appropriate sinus** 

A lack of identification remains possible. Diagnosis of anomalous connection with the appropriate sinus is usually only suspected with X-ray coronary angiography, and

**6.1.4 Angiographic diagnosis of anomalous connection with the non-coronary sinus** 

of angiographic views is often ambiguous and needs complementary imaging.

**6.1.6 Angiographic diagnosis of single coronary artery (type VI)** 

visualize the whole coronary circulation.

**6.1.5 Angiographic diagnosis of anomalous connection above the sinotubular** 

Angiographic diagnosis of anomalous origin from the non-coronary sinus is always challenging with frequent difficulties of a selective canulation. Moreover, the interpretation

Difficulties in identifying a high take-off from the aorta by conventional angiography are non unusual. Many catheters, similar to these used for saphenous vein grafts, are often required. Moreover, an initial intramural course may make selective injections more difficult. Finally, the distinction between a normal variant of origin and a high take-off at least 10 mm above the sinotubular junction is ambiguous in most cases. Once again, the coronary CT angiography will be able to delineate accurately the level of the coronary

The diagnosis of a single coronary artery is easy with a single orifice in the appropriate sinus and the lack of ectopic proximal course. All major coronary arteries course the atrioventricular and interventricular grooves. Coronary angiography needs large fields to

**6.1.7 Angiographic diagnosis of anomalous connection with the pulmonary artery** 

Conventional angiography of anomalous connection with the pulmonary artery is not always easy. Indeed, the contralateral artery, mostly the RCA, is considerably enlarged with an ostial diameter around 10 mm and a diffused dilation of the artery, making a selective

Obviously, angiographic diagnosis of anomalous connection with the contralateral artery is usually easy, with the exception of a too selective angiography leading to a misdiagnosis, for example an ectopic CX coronary artery originated from the proximal

aberrant circumflex coronary artery.

contribution of tomographic imaging is essential.

**(type II)** 

**(type III)** 

**(type IV)** 

ostia.

**(type VII)** 

**junction (type V)** 

segment of the RCA.

an incomplete visualization of the ectopic vessel, leading to an erroneous diagnosis, particularly if the angiographer is not aware with the congenital coronary abnormalities. In addition, the selective coronary angiography is not able to analyse the shape of the ectopic orifice, to quantify a hypoplasic segment exactly, or to identify an intramural course. Despite these limitations, often some angiographic views typically make an interpretation easier.

#### **6.1.1 Angiographic diagnosis of anomalous connection with the opposite sinus (type I)**

Selective angiography of some ANOCOR arising from the opposite sinus may be a challenge, especially with the RCA. The origin of the latter is often characteristic with an orifice at the level of the sinotubular junction and close to the commissural zone between the right and the left coronary cusps. The two ostia are generally non adjacent, which explains why the catheter used for the LCA does not generally find the ectopic right orifice. Other catheters (Judkins right, Amplatz left) are required. Nevertheless, the ellipsoid shape of the orifice and the lack of orthogonal take-off, explain the non rare failures of satisfactory angiography. Instead of an additional aortography, usually not very contributory, a tomographic imaging will allow the diagnosis of ANOCOR to be confirmed or not. When selective angiography is possible, the views of an ectopic RCA originated from the left sinus are typical, with a normal or slightly enlarged ostial lumen in the 30° left anterior oblique (LAO) projection, while a narrowing of the first segment is visible in the 30° right anterior oblique (RAO) projection, expressing the ellipsoid shape of the orifice and the initial intramural course (figure 13).

Fig. 13. Selective angiogram of an anomalous connection of the right coronary artery with the left sinus in 20° left anterior oblique projection (A) and left 30° right anterior oblique projection (B) with a schematic representation of X-ray plane (arrow).

an incomplete visualization of the ectopic vessel, leading to an erroneous diagnosis, particularly if the angiographer is not aware with the congenital coronary abnormalities. In addition, the selective coronary angiography is not able to analyse the shape of the ectopic orifice, to quantify a hypoplasic segment exactly, or to identify an intramural course. Despite these limitations, often some angiographic views typically make an interpretation easier.

Selective angiography of some ANOCOR arising from the opposite sinus may be a challenge, especially with the RCA. The origin of the latter is often characteristic with an orifice at the level of the sinotubular junction and close to the commissural zone between the right and the left coronary cusps. The two ostia are generally non adjacent, which explains why the catheter used for the LCA does not generally find the ectopic right orifice. Other catheters (Judkins right, Amplatz left) are required. Nevertheless, the ellipsoid shape of the orifice and the lack of orthogonal take-off, explain the non rare failures of satisfactory angiography. Instead of an additional aortography, usually not very contributory, a tomographic imaging will allow the diagnosis of ANOCOR to be confirmed or not. When selective angiography is possible, the views of an ectopic RCA originated from the left sinus are typical, with a normal or slightly enlarged ostial lumen in the 30° left anterior oblique (LAO) projection, while a narrowing of the first segment is visible in the 30° right anterior oblique (RAO) projection, expressing the ellipsoid shape of the orifice and the initial

**A B** 

Fig. 13. Selective angiogram of an anomalous connection of the right coronary artery with the left sinus in 20° left anterior oblique projection (A) and left 30° right anterior oblique

projection (B) with a schematic representation of X-ray plane (arrow).

**6.1.1 Angiographic diagnosis of anomalous connection with the opposite sinus** 

**(type I)** 

intramural course (figure 13).

The ectopic orifice of the left coronary artery (LMCA, LAD coronary artery or CX coronary artery) is in most cases very close to the right coronary orifice, and sometimes contiguous. Thus, a selective angiography is generally easier using Judkins right catheter or Amplatz left or right catheters. A multipurpose catheter may be useful to catheterize the orifice of an aberrant circumflex coronary artery.

### **6.1.2 Angiographic diagnosis of anomalous connection with the contralateral artery (type II)**

Obviously, angiographic diagnosis of anomalous connection with the contralateral artery is usually easy, with the exception of a too selective angiography leading to a misdiagnosis, for example an ectopic CX coronary artery originated from the proximal segment of the RCA.

#### **6.1.3 Angiographic diagnosis of anomalous connection with the appropriate sinus (type III)**

A lack of identification remains possible. Diagnosis of anomalous connection with the appropriate sinus is usually only suspected with X-ray coronary angiography, and contribution of tomographic imaging is essential.
