Best Angiographic View for Anomalous Circumflex from Right Coronary Artery
The lateral view is the single best angiographic projection for demonstrating an anomalous circumflex artery originating from the right coronary artery or right sinus of Valsalva, as this retroaortic course is optimally visualized in this projection. 1
Primary Angiographic Approach
Perform the lateral view as your primary diagnostic projection to visualize the retroaortic course of the anomalous circumflex artery, which consistently travels posterior to the aorta when originating from the right sinus or right coronary artery 1
The standard RAO and LAO views are inadequate for defining the three-dimensional course of this anomaly, as conventional coronary angiography may fail to determine the precise spatial relationship of the anomalous vessel 2
Supplementary Angiographic Views
Add caudal RAO angulation to improve visualization of the proximal circumflex origin and its course, as this view increases diagnostic accuracy in 88% of proximal circumflex segments and identifies 22% of lesions missed on standard projections 3
Use cranial RAO views to assess the distal circumflex segments and marginal branches, which improves visualization in 69% of distal circumflex segments 3
Critical Anatomic Features to Document
Confirm the retroaortic course of the anomalous circumflex, as all aberrant circumflex arteries from the right sinus or right coronary artery follow this posterior path around the aorta 1
Assess for atherosclerotic disease, which occurs in approximately 35% of anomalous circumflex arteries and may develop earlier and more aggressively than in normal coronaries 1, 2
Document the size of the myocardial territory supplied, as some anomalous circumflex arteries irrigate only a small area of myocardium 1
Advanced Imaging for Complete Evaluation
Obtain coronary CT angiography after conventional angiography to definitively establish the three-dimensional course and spatial relationships that cannot be fully determined by catheter-based imaging alone 2, 4
CT angiography provides 0.5-0.6 mm isotropic spatial resolution and allows for 3D reconstruction to visualize the entire retroaortic course 4
Clinical Significance
This anomaly is generally benign, but the presence of atherosclerotic disease or a small territory of myocardium supplied should be documented, as these factors may influence clinical management 1, 4
Unlike anomalous left coronary arteries from the right sinus, anomalous circumflex arteries from the right do not carry significant risk of sudden cardiac death due to their retroaortic (not interarterial) course 4, 1