Coronary Artery Coronary Artery Anomalies On CT Anomalies On CT

AngiographyAngiography

Dr.Sahar Gamal El-Dr.Sahar Gamal El-Din ,CBCCTDin ,CBCCT

National Heart InstituteNational Heart Institute

Introduction• The prevalence of coronary artery

anomalies is reported to be approximately 1% to 2% in the general population .

• The clinical presentation is variable & the abnormality may remain clinically occult or it can have life-threatening consequences, such as MI, arrhythmia, or even sudden death.

• Even if the anomalies are asymptomatic, knowledge of their presence is important at cardiac surgery to avoid damage to a vessel with an anomalous course.

• The diagnosis of coronary artery anomalies has The diagnosis of coronary artery anomalies has previously required invasive coronary previously required invasive coronary angiography; however, in up to 50% of angiography; however, in up to 50% of patients, the coronary artery anomalies may be patients, the coronary artery anomalies may be incorrectly classified during invasive incorrectly classified during invasive angiography.angiography.

• This misclassification may result from the This misclassification may result from the difficulty in delineating the precise vessel path difficulty in delineating the precise vessel path within a complex 3D geometry using a within a complex 3D geometry using a relatively restricted two-dimensional view. relatively restricted two-dimensional view.

• Coronary CTA has been shown to accurately the Coronary CTA has been shown to accurately the anomalous vessel origin, its subsequent anomalous vessel origin, its subsequent course, and the relationship to the great course, and the relationship to the great vessels. vessels.

Classification Classification

• Anomalies of origin.Anomalies of origin.• Anomalies of course.Anomalies of course.• Anomalies of termination.Anomalies of termination.• Intrinsic Intrinsic

Anomalies of OriginAnomalies of Origin• 1. Number of Coronary Ostia.1. Number of Coronary Ostia. Normally there  Normally there

are 2 coronary ostia (one for the right are 2 coronary ostia (one for the right coronary artery and one for the left).coronary artery and one for the left).

A.A.Multiple Ostia.Multiple Ostia. Three or more ostia  Three or more ostia ( considered normal variants). This is most ( considered normal variants). This is most commonly due to the conus branch arising commonly due to the conus branch arising directly from the aorta, which is seen in 50% directly from the aorta, which is seen in 50% of subjects .of subjects .

• The other common cause of multiple ostia is The other common cause of multiple ostia is an absent left main artery with separate an absent left main artery with separate ostia for the LAD and LCX (estimated to be ostia for the LAD and LCX (estimated to be seen in 0.5% to 8% of population seen in 0.5% to 8% of population

(A and B) Multiple coronary ostia. Note the separate origin of the conus artery from the aorta (curved black arrow) on 3-D volume-rendered and multiplanar reformatted CT image.

• Absence of the left main coronary artery (so-called split left coronary artery). The LAD and the LCX arise separately (arrow) from the left sinus of Valsalva of the aorta (Ao) Panel A shows a cranial view of a 3D volume-rendered image. The separate ostia cannot be recognized definitely. Better evaluation is possible on a volume-rendered reconstruction of the coronary tree (Panel B) or a 2-dDmap view (Panel C)

B.B. Single Coronary Ostium Single Coronary Ostium • In this rare anomaly only one coronary In this rare anomaly only one coronary

artery arises from a single ostium artery arises from a single ostium (0.0024% to 0.044% of the population).(0.0024% to 0.044% of the population).

• It gives rise to the left main and RCA or It gives rise to the left main and RCA or courses directly to the LAD, LCX, & RCA. courses directly to the LAD, LCX, & RCA. 

• One or more arteries can have an One or more arteries can have an anomalous course. This abnormality can anomalous course. This abnormality can have an adverse clinical outcome, have an adverse clinical outcome, particularly if one of the arteries takes particularly if one of the arteries takes an interarterial course.an interarterial course.

• Prepulmonary benign course of the left coronary artery arising from the RCA after a short common trunk, which originates from the right sinus of Valsalva. The anomalously coursing left coronary artery passes anterior to the pulmonary artery to the anterior interventricular sulcus, where it splits into LAD and LCX.

• Prepulmonary benign course of the left coronary artery arising from the RCA after a short common trunk, which originates from the right sinus of Valsalva.

• Anomalous coronary artery anatomy with a single coronary ostium arising from the right coronary cusp giving off a left main taking a retroaortic course and a right coronary artery. (a) 3D reconstruction of the coronary arteries. (b) Double-oblique maximal intensity projection (MIP).

• 2. Anomalous Location of Ostium in 2. Anomalous Location of Ostium in Relation to the Appropriate Coronary Relation to the Appropriate Coronary Sinus.Sinus.  

• A. High ostium.A. High ostium. This refers to a coronary This refers to a coronary ostium (either Lt or Rt) that is at least ostium (either Lt or Rt) that is at least 1 cm1 cm above the sinotubular junction (instead of above the sinotubular junction (instead of being at the aortic sinus).being at the aortic sinus).

• Rarely, the coronary artery can arise from Rarely, the coronary artery can arise from

the aortic arch, the brachiocephalic artery, the aortic arch, the brachiocephalic artery, the internal mammary, bronchial, or the internal mammary, bronchial, or subclavian arteries, or even the descending subclavian arteries, or even the descending aorta.aorta.

• These situations are usually well These situations are usually well tolerated & asymptomatic, but they tolerated & asymptomatic, but they may cause difficulties in cannulation may cause difficulties in cannulation during coronary angio. & CABG.during coronary angio. & CABG.

• B. Commissural Ostium.B. Commissural Ostium. When the When the ostium is located within 5 mm of the ostium is located within 5 mm of the commissure between 2 sinuses, it is commissure between 2 sinuses, it is termed a commissural ostium. termed a commissural ostium.

3-D volume-rendered image of coronary tree shows a high origin of the RCA (black curved arrow) above the sinotubular junction.

• 3. Anomalous Origin of the Coronary 3. Anomalous Origin of the Coronary Artery from Opposite Sinus.Artery from Opposite Sinus.

•    In this anomaly, the coronary artery In this anomaly, the coronary artery arises from the opposite sinus & then arises from the opposite sinus & then takes one of the 4 paths . takes one of the 4 paths .

• The precise path taken by the artery is The precise path taken by the artery is important clinically. important clinically.

• An interarterial course (called malignant An interarterial course (called malignant course) carries a high risk of sudden course) carries a high risk of sudden cardiac death, while the other 3 courses cardiac death, while the other 3 courses are considered nonmalignant or relatively are considered nonmalignant or relatively benign. benign.

• A. Interarterial. A. Interarterial. 

• In this case, a coronary artery In this case, a coronary artery (such as the RCA, LM, LAD or LCX) (such as the RCA, LM, LAD or LCX) arises from the opposite sinus & arises from the opposite sinus & courses between the aortic root courses between the aortic root and pulmonary artery/right and pulmonary artery/right ventricular outflow tract . ventricular outflow tract .

• This anomaly has been linked This anomaly has been linked with sudden cardiac death. with sudden cardiac death.

• Several pathologic processes have been Several pathologic processes have been implicated; they include a narrow slit-like implicated; they include a narrow slit-like orifice, an acute angle of the ostium with a orifice, an acute angle of the ostium with a tangential proximal course of the ectopic tangential proximal course of the ectopic coronary artery, and an intramural course coronary artery, and an intramural course where the coronary artery exits the aortic where the coronary artery exits the aortic lumen and courses into the aortic wall lumen and courses into the aortic wall before emerging on the surface. before emerging on the surface.

• A consequence of this anomaly is lateral A consequence of this anomaly is lateral arterial compression, which worsens in arterial compression, which worsens in systole, and the artery appears ovoid in systole, and the artery appears ovoid in cross-section. The flow can be further cross-section. The flow can be further compromised during exercise due to aortic compromised during exercise due to aortic dilatation.dilatation.

• RCA arising from the left coronary sinus and taking an interarterial course (a) VRT image of the top of the heart shows both the RCA (straight arrow) and the LCA (curved arrow) originating from the left coronary sinus. The RCA courses between the pulmonary artery (PA) and the aorta (A).Note the slit-like ostium (arrowhead) of the RCA.

VRT of single coronary ostium in the left sinus of Valsalva (LSV). VRT of single coronary ostium in the left sinus of Valsalva (LSV). The dilated LMT divided into the LAD and the LCX .The LCX then The dilated LMT divided into the LAD and the LCX .The LCX then coursed in the left atrioventricular groove and continued to the coursed in the left atrioventricular groove and continued to the posterior atrioventricular groove where it occupied the anatomic posterior atrioventricular groove where it occupied the anatomic position normally occupied by RCA.position normally occupied by RCA.

(a) RCA and LCA origin from the ascending aorta above the left (a) RCA and LCA origin from the ascending aorta above the left sinus of Valsalva together, (b) RCA passed between the aorta and sinus of Valsalva together, (b) RCA passed between the aorta and pulmonary artery before reaching the right atrioventricular groove.pulmonary artery before reaching the right atrioventricular groove.

• B. Transseptal (subpulmonic).B. Transseptal (subpulmonic).  

• The artery traverses anteriorly & The artery traverses anteriorly & inferiorly through the interventricular inferiorly through the interventricular septum & takes an intramyocardial septum & takes an intramyocardial course, giving off septal branches and course, giving off septal branches and finally emerging at its normal finally emerging at its normal epicardial position. It is considered a epicardial position. It is considered a relatively benign anomaly, though in relatively benign anomaly, though in some cases of sudden & unexpected some cases of sudden & unexpected cardiac death it has been found to be cardiac death it has been found to be the only reported abnormality the only reported abnormality

trans-septal LAD artery that arises trans-septal LAD artery that arises from the RCAfrom the RCA

• C. Retroaortic.C. Retroaortic. This is the most common This is the most common coronary artery anomaly, seen in 0.9% coronary artery anomaly, seen in 0.9% of the population. The ectopic coronary of the population. The ectopic coronary artery (more commonly the LCX) runs artery (more commonly the LCX) runs posteriorly between the aortic root and posteriorly between the aortic root and the left atrium.the left atrium.

• D. Prepulmonic.D. Prepulmonic. The ectopic coronary  The ectopic coronary artery runs anterior to the pulmonary artery runs anterior to the pulmonary artery or right ventricular outflow tract artery or right ventricular outflow tract

• LCx artery arising from the right coronary sinus and taking a retroaortic course

Anomalous retroaortic course of the left circumflex artery (LCX) (black arrow) arising from right coronary artery in two separate subjects as seen on volume-rendered (A) and axial contrast-enhanced CT image (B).

Axial contrast-enhanced CT image showing anomalous LAD and LCX arising from the right sinus of Valsalva. The LAD courses anterior to the RVOT (i.e. prepulmonic) while the LCX courses posterior to the aortic root (retroaortic).

4.4. Inverted Coronary Arteries.Inverted Coronary Arteries.  • In this rare anomaly, the LCA arises from In this rare anomaly, the LCA arises from

the right aortic sinus, and the RCA arises the right aortic sinus, and the RCA arises from the left aortic sinus. The anomaly can from the left aortic sinus. The anomaly can become hemodynamically significant if the become hemodynamically significant if the anomalous artery courses interarterially.anomalous artery courses interarterially.

5.5. Anomalous origin of the coronary artery Anomalous origin of the coronary artery from non-coronary sinus.from non-coronary sinus. Either the RCA or Either the RCA or the LM can arise from the non-coronary the LM can arise from the non-coronary sinus. sinus.

• This is a rare anomaly and may have no This is a rare anomaly and may have no clinical relevance . However, there are clinical relevance . However, there are reports of cases that can be symptomatic, reports of cases that can be symptomatic, particularly if the proximal part of the particularly if the proximal part of the artery has an intramural course inside the artery has an intramural course inside the aortic wall and is hypoplastic.aortic wall and is hypoplastic.

• Anomalous origin of the left main artery from non-coronary sinus

6.6. Anomalous Origin of the Coronary Artery from Anomalous Origin of the Coronary Artery from Pulmonary Artery (ALCAPA – ARCAPA)).Pulmonary Artery (ALCAPA – ARCAPA)).  

• This is one of the most serious anomalies, with a This is one of the most serious anomalies, with a 90% mortality rate in the first year of life. Most 90% mortality rate in the first year of life. Most patients are symptomatic in infancy and early patients are symptomatic in infancy and early childhood. childhood.

• Either the LCA (ALCAPA)Either the LCA (ALCAPA) also referred to as also referred to as Bland–White–Garland syndromeBland–White–Garland syndrome or the RCA or the RCA (ALCAPA) can arise from the pulmonary artery. (ALCAPA) can arise from the pulmonary artery.

• ALCAPA appears more common (0.008% vs ALCAPA appears more common (0.008% vs 0.002% for RCA). It is conceivable that this 0.002% for RCA). It is conceivable that this apparent difference may be due to the fact that apparent difference may be due to the fact that ALCAPA carries a worse prognosis and is more ALCAPA carries a worse prognosis and is more likely to come to clinical attention. likely to come to clinical attention.

• In rare instances the LCX or both the RCA and the In rare instances the LCX or both the RCA and the LCA can take origin from the pulmonary artery.LCA can take origin from the pulmonary artery.

• Coronary artery origin from the pulmonary Coronary artery origin from the pulmonary artery can occur as an isolated finding, artery can occur as an isolated finding, though an associated cardiac abnormality, though an associated cardiac abnormality, such as ASD, VSD, tetralogy of Fallot, aortic such as ASD, VSD, tetralogy of Fallot, aortic coarctation, DORV, and PDA, can be seen in coarctation, DORV, and PDA, can be seen in 5% of cases. 5% of cases.

• Extensive intercoronary collaterals develop Extensive intercoronary collaterals develop that are often dilated and tortuous. that are often dilated and tortuous. Symptoms usually occur due to coronary Symptoms usually occur due to coronary steal phenomenon caused by the flow of steal phenomenon caused by the flow of blood from the higher pressure coronary blood from the higher pressure coronary arterial system to the lower pressure arterial system to the lower pressure pulmonary arteries.Surgical treatment is pulmonary arteries.Surgical treatment is usually recommended for these anomalies.usually recommended for these anomalies.

• Volume-rendered image of a Bland-White-Garland syndrome in a right anterior oblique view. The RCA is dilated. The LAD originates from the pulmonary artery (arrow) and is also markedly dilated and tortuous.

VRT CT angiogram shows dilated intercoronary VRT CT angiogram shows dilated intercoronary collateral arteries (arrowheads), which connect the collateral arteries (arrowheads), which connect the tortuous RCA (long arrow) to the LCA (short arrow).tortuous RCA (long arrow) to the LCA (short arrow).

Anomalous origin of the right coronary Anomalous origin of the right coronary artery from pulmonary artery (ARCAPA).artery from pulmonary artery (ARCAPA).

• Anomalous origin of the right coronary artery (black arrow) from pulmonary artery. Note the dilated tortuous coronary artery and multiple collaterals.

Anomalies of CourseAnomalies of Course• 1. Myocardial Bridge.. Myocardial Bridge.  In this In this

anomaly, a portion of the coronary anomaly, a portion of the coronary artery that is normally epicardial artery that is normally epicardial traverses through the myocardium. The traverses through the myocardium. The myocardial tissue covering the artery is myocardial tissue covering the artery is called a myocardial bridge, and the called a myocardial bridge, and the artery itself is called a tunneled artery itself is called a tunneled segment.segment.

•   The bridging can be superficial or deep The bridging can be superficial or deep and has been most commonly described and has been most commonly described in the mid LAD—80% .in the mid LAD—80% .

• The myocardial bridge is diagnosed on The myocardial bridge is diagnosed on catheter angiography by observing systolic catheter angiography by observing systolic compression of the artery, or the so-called compression of the artery, or the so-called "milking effect.""milking effect." Angiography may be Angiography may be somewhat insensitive to superficial bridging somewhat insensitive to superficial bridging that does not cause significant systolic that does not cause significant systolic compression.compression.

• However, coronary CTA can demonstrate the However, coronary CTA can demonstrate the coronary artery directly(not just the lumen) coronary artery directly(not just the lumen) and its relationship to the adjacent and its relationship to the adjacent myocardium. myocardium.

• The length and depth of tunneled segment can The length and depth of tunneled segment can be accurately determined by CT. be accurately determined by CT.

• Additional indirect signs (such as systolic Additional indirect signs (such as systolic compression) can also be seen using compression) can also be seen using retrospectively-gated coronary CT through retrospectively-gated coronary CT through different phases of the cardiac cycle. different phases of the cardiac cycle.

• This capability of CT may explain the This capability of CT may explain the higher prevalence of myocardial higher prevalence of myocardial bridging reported on CT (26%) bridging reported on CT (26%) compared to conventional angiography compared to conventional angiography (0.5% to 4.5%).(0.5% to 4.5%).

• Though myocardial bridging can be Though myocardial bridging can be seen as a normal variant, without being seen as a normal variant, without being clinically overt in a large proportion of clinically overt in a large proportion of cases, it has been infrequently linked cases, it has been infrequently linked with ischemia, tachycardia-induced with ischemia, tachycardia-induced ischemia, conduction disturbances, ischemia, conduction disturbances, myocardial infarctions, and even myocardial infarctions, and even sudden cardiac death.sudden cardiac death.

•  Additionally, the coronary segment Additionally, the coronary segment proximal to the tunneled artery is proximal to the tunneled artery is vulnerable to atherosclerotic disease vulnerable to atherosclerotic disease presumably due to low-wall shear stress, presumably due to low-wall shear stress, while the tunneled segment itself may be while the tunneled segment itself may be protected because of high-wall shear stress. protected because of high-wall shear stress.

• Myocardial bridging (black arrow) as seen on a curved planar Myocardial bridging (black arrow) as seen on a curved planar reformatted image of the LAD (A). Note the decrease in caliber of reformatted image of the LAD (A). Note the decrease in caliber of the artery in systole (C) compared to diastole (B) on a cross-the artery in systole (C) compared to diastole (B) on a cross-sectional orthogonal view of the LAD.sectional orthogonal view of the LAD.

• 2. Duplication.2. Duplication. This anomaly refers mainly to 2 This anomaly refers mainly to 2 LAD arteries (9 types): Type 1 is the most common, LAD arteries (9 types): Type 1 is the most common, one short LAD, which terminates in the anterior one short LAD, which terminates in the anterior interventricular groove without reaching the apex, interventricular groove without reaching the apex, and one long LAD, which originates from the LAD and one long LAD, which originates from the LAD proper or anomalously from the RCA/opposite proper or anomalously from the RCA/opposite sinus, enters the distal anterior interventricular sinus, enters the distal anterior interventricular groove, and terminates at the apex. groove, and terminates at the apex.

• Care should be taken to avoid mistaking a long Care should be taken to avoid mistaking a long LAD for a parallel diagonal branch. LAD for a parallel diagonal branch. The differentiation is relatively The differentiation is relatively straightforward, since a diagonal artery does not straightforward, since a diagonal artery does not enter the anterior interventricular enter the anterior interventricular groove . Knowledge of this anomaly is important groove . Knowledge of this anomaly is important for planning surgical vascularization & to avoid for planning surgical vascularization & to avoid mistaking a short LAD artery for a mid-LAD mistaking a short LAD artery for a mid-LAD occlusion. occlusion.

• Duplication of LAD seen on volume-rendered image of the heart (A) and coronary tree image (B). Note a short LAD (black arrow), which terminates high in the anterior interventricular groove without reaching the apex and a long LAD (white arrow) which courses parallel to the short LAD, enters the distal anterior interventricular groove and supplies the apex.

Duplication of RCADuplication of RCA

Anomalies of Termination• 1. Coronary Arteriovenous Fistula.Coronary Arteriovenous Fistula. • Coronary artery fistula is a condition in Coronary artery fistula is a condition in

which a communication exists between which a communication exists between one or two coronary arteries and either:one or two coronary arteries and either:

a.a.A cardiac chamberA cardiac chamberb.b.The coronary sinusThe coronary sinusc.c.The superior vena cavaThe superior vena cavad.d.The pulmonary arteryThe pulmonary artery • The involved fistulous artery is often The involved fistulous artery is often

dilated and tortuous.dilated and tortuous.

• The most common site of drainage is the The most common site of drainage is the right ventricle (45% of cases), followed by right ventricle (45% of cases), followed by the right atrium (25%) and the pulmonary the right atrium (25%) and the pulmonary artery (15%). The fistula drains into the left artery (15%). The fistula drains into the left atrium or left ventricle in less than 10% of atrium or left ventricle in less than 10% of cases.cases.

• There may be steal phenomenon with There may be steal phenomenon with consequent myocardial ischemia. Drainage consequent myocardial ischemia. Drainage to a left-sided heart chamber causes a to a left-sided heart chamber causes a hemodynamic state similar to aortic hemodynamic state similar to aortic regurgitation.regurgitation.

• Clinical symptoms are based on the induced Clinical symptoms are based on the induced hemodynamic abnormality. If the patient is hemodynamic abnormality. If the patient is symptomatic, treatment options include symptomatic, treatment options include closing the fistula, either by coil closing the fistula, either by coil embolization or by ligation of the fistula with embolization or by ligation of the fistula with or without CABG.or without CABG.

• Fistula between the RCA and the coronary sinus (CS) depicted by three-dimensional reconstruction (Panel A) and multiplanar reformation (Panel B).

• Fistula between the LAD and the right ventricle displayed on three-dimensional reconstructions (Panel C) and the corresponding conventional angiogram (Panel D).

Fistula between proximal LAD and Fistula between proximal LAD and MPAMPA

• 2. Coronary Arcade.2. Coronary Arcade. • This is defined as angiographically evident This is defined as angiographically evident

connections between the RCA and LCA in the connections between the RCA and LCA in the absence of coronary stenosis. Though small absence of coronary stenosis. Though small connections between the RCA and LCA are connections between the RCA and LCA are normal, these are not normally large enough normal, these are not normally large enough to be visible on angiography. to be visible on angiography.

• These connections differ from collaterals by These connections differ from collaterals by virtue of straight connections between the virtue of straight connections between the coronaries in the absence of significant coronaries in the absence of significant coronary artery diseasecoronary artery disease

• Coronary arcades are mainly seen near the Coronary arcades are mainly seen near the crux of the heart crux of the heart

• 3. Extracardiac connections.3. Extracardiac connections. • Coronary arteries may have Coronary arteries may have

connections to extracardiac arteries, connections to extracardiac arteries, such as the bronchial, internal such as the bronchial, internal mammary, pericardial, superior and mammary, pericardial, superior and inferior pherenic, intercostals, and inferior pherenic, intercostals, and esophageal branches of the aorta.esophageal branches of the aorta.

•   These connections become significant These connections become significant with the development of coronary with the development of coronary artery disease.artery disease.

Intrinsic Coronary Arterial Intrinsic Coronary Arterial AbnormalitiesAbnormalities

• 1. Coronary stenosis.1. Coronary stenosis. Though coronary  Though coronary stenosis is mostly acquired, congenital stenosis is mostly acquired, congenital coronary stenosis has been described and can coronary stenosis has been described and can be ostial (due to a valve-like ridge of the be ostial (due to a valve-like ridge of the aortic wall or fusion of the aortic leaflets and aortic wall or fusion of the aortic leaflets and aortic wall) or peripheral. aortic wall) or peripheral.

• 2. Congenital Atresia of the CA (mostly 2. Congenital Atresia of the CA (mostly LMCA).LMCA).

• In this condition there is complete atresia of In this condition there is complete atresia of the left coronary ostium , so the entire the left coronary ostium , so the entire coronary arterial supply to the heart is coronary arterial supply to the heart is derived from the RCA and its branches. The derived from the RCA and its branches. The LAD and LCX are seen in their respective LAD and LCX are seen in their respective locations , but they receive blood from the locations , but they receive blood from the RCA. RCA.

• This is an extremely rare condition and This is an extremely rare condition and differs from a single RCA because some differs from a single RCA because some of the branches fill retrograde through of the branches fill retrograde through the RCA. The collateral circulation from the RCA. The collateral circulation from the right to the left coronary system is the right to the left coronary system is usually not sufficient so almost all usually not sufficient so almost all patients eventually develop myocardial patients eventually develop myocardial ischemia. ischemia.

• Surgical reconstruction of a 2-coronary Surgical reconstruction of a 2-coronary system by coronary artery bypass graft system by coronary artery bypass graft is performed in these patients.is performed in these patients.

Congenital Atresia of the LMCA Congenital Atresia of the LMCA

• 3. Coronary Artery Ectasia or Aneurysm.3. Coronary Artery Ectasia or Aneurysm. • This lesion is defined as a coronary artery This lesion is defined as a coronary artery

with a diameter of more than 1.5 times the with a diameter of more than 1.5 times the adjacent normal segment and can be either adjacent normal segment and can be either focal or diffuse. focal or diffuse.

• Coronary aneurysms may be congenital or Coronary aneurysms may be congenital or acquired; in the acquired group, Kawasaki acquired; in the acquired group, Kawasaki disease is the most common cause of disease is the most common cause of aneurysms worldwide.aneurysms worldwide.  

• Congenital aneurysms are more commonly Congenital aneurysms are more commonly described in the RCA.described in the RCA.

• Possible complications include myocardial Possible complications include myocardial infarction from embolization of thrombus. infarction from embolization of thrombus.

Right sinus of Valsalva aneurysmRight sinus of Valsalva aneurysm