Introduction: Increased use of cardiac imaging leads to earlier identification of coronary artery anomalies (CAA) (1,2). Multimodality imaging and functional tests could be crucial in CAA diagnosis and management (1,3). Routine echocardiography plays a key role in their detection, as CAA are often diagnosed incidentally (3).
Case report: 60-year-old patient with insulin-dependent diabetes presented with non-ST-elevation acute myocardial infarction (non-ST-elevation inferior changes; hsT I 2329.3 ng/L) to the Šibenik General Hospital. On transthoracic echocardiogram, there was a mild basal inferior hypo-contractility, with no other pathological abnormality described. The patient was transferred for urgent coronary angiography at the University Hospital Centre Split, revealing a single coronary artery arising from the right coronary cusp with subtotal stenosis of the right coronary artery as the culprit lesion. Percutaneous coronary intervention with one drug-eluting stent was successfully performed. To further define CAA and its course, computed tomography was done confirming the abovementioned findings (Figure 1). The circumflex artery exhibited a retro-aortic course, while the left anterior descending artery followed a pre-pulmonic course. After one year, the patient developed angina recurrence and was referred for invasive angiography. A significant (~80%) in-stent restenosis of the right coronary artery and a subtotal (~95%) stenosis of the circumflex branch were observed and successfully treated with drug-coated balloons (Figure 2). The transthoracic echocardiography was again performed, showing clear signs of CAA (Figure 3) and emphasizing a distinct long and tortuous course of left coronary artery branches, potentially precipitating this patient for turbulent flow and accelerated atherosclerosis (2).
Conclusion: Echocardiography is a useful modality for early detection of the retro-aortic circumflex artery, although such findings could remain undetected in daily clinical settings (1,2). Despite CAA usually being benign, their timely detection is important as it could be associated with coronary disease (2). To this patient, it would mean closer cardiac supervision and clinical follow-up.