From the Guidelines
An anomalous circumflex artery with retro-aortic course is generally considered a benign coronary artery anomaly that typically doesn't require specific treatment in asymptomatic individuals. This condition occurs when the left circumflex artery originates from the right coronary artery or right sinus of Valsalva and travels behind (posterior to) the aorta to reach its normal distribution territory. For most patients with this anomaly, no intervention is necessary as it rarely causes ischemia or clinical symptoms 1. However, if a patient experiences chest pain, arrhythmias, or other cardiac symptoms that can be attributed to this anomaly, further evaluation with cardiac CT angiography or conventional coronary angiography is recommended.
Key Considerations
- The benign nature of this anomaly is due to its anatomical course, which unlike other coronary anomalies (such as those passing between the aorta and pulmonary artery), doesn't typically subject the vessel to compression during exercise or increased cardiac output 1.
- Regular cardiac follow-up is still advisable for patients with this finding to monitor for any developing symptoms.
- In symptomatic cases where the anomaly causes compression or kinking of the vessel, surgical correction may be considered, though this is uncommon 1.
- The management of patients should take age into account, with heightened concern about the risk of sudden death in younger patients 1.
Diagnostic Approach
- Resting ECG, echocardiography, and even exercise testing frequently are not able to show any abnormal findings in patients with anomalous circumflex artery with retro-aortic course 1.
- Multi-slice contrast-enhanced CT or CT coronary angiography are primary diagnostic tools for evaluating coronary artery anomalies 1.
- Cardiac CMR may also be an option for diagnosing coronary artery anomalies, particularly in adolescent patients to limit radiation exposure 1.
Treatment
- Surgical correction is typically not required for asymptomatic patients with anomalous circumflex artery with retro-aortic course. However, in symptomatic cases, surgical repair may be indicated to alleviate symptoms and prevent sudden cardiac death 1.
- The decision to perform surgical correction should be individualized and based on the presence of symptoms, ischemia, and other factors that may contribute to ventricular arrhythmias 1.
From the Research
Anomalous Circumflex Artery with Retro Aortic Course
- The anomalous circumflex artery with a retro aortic course is a rare coronary artery anomaly, found in approximately 0.6% to 1.55% of patients who undergo coronary angiography 2.
- This anomaly can be benign, but it may also cause myocardial ischemia and sudden death, making its reliable identification crucial 2, 3.
- Studies have shown that the anomalous left circumflex artery (ALCx) can originate from the right sinus of Valsalva or as a proximal branching of the Right Coronary Artery (RCA) 3, 4.
- The clinical presentation of ALCx can vary from asymptomatic to angina or myocardial infarction, and it may be associated with atherosclerotic lesions or kinking/compression of the vessel 3, 5.
- Research has suggested that the anomalous circumflex artery with a retro aortic course may be predisposed to selective atherosclerosis, particularly in vessels arising from the right side 5.
- However, other studies have found that this anomaly appears to be benign, with no increased occurrence of atherosclerosis relative to other coronary arteries 4.
- The anomalous circumflex artery can be visualized on transthoracic echocardiogram, and its identification is important to avoid misinterpreting it as artifacts or other cardiac structures 6.
- In cases of anomalous circumflex artery, coronary computed tomography angiography can be used to confirm the diagnosis and evaluate the extent of atherosclerotic disease 6.