Kini et al.
C a rd i a c I m ag i n g • P i c t o r i a l E s s ay
CT Angiography of
Coronary Arterial and
Venous Anatomy
Normal and Variant Coronary
Arterial and Venous Anatomy on
High-Resolution CT Angiography
Sunil Kini1, 2 OBJECTIVE. This article displays the normal and variant anatomy of the coronary arteries
Kostaki G. Bis2 and subjacent cardiac veins using a high-resolution 64-MDCT scanner.
Leroy Weaver2, 3 CONCLUSION. Knowledge of the anatomy of the coronary arteries and subjacent car-
diac veins as displayed with maximum intensity and volume-rendered projections is important
Kini S, Bis KG, Weaver L for correct image interpretation of coronary CT angiography examinations.
ontrast-enhanced CT angiography
C (CTA) of the coronary arteries is
becoming feasible as temporal and
spatial resolution improves with
the availability of MDCT. Detection, charac-
terization, and quantification of coronary ar-
tery disease and elegant delineation of coro-
nary anatomy are possible using 2D
multiplanar reformation (MPR), 3D maxi-
mum-intensity-projection (MIP), and 3D vol-
ume-rendered postprocessing techniques. Fa-
miliarity with coronary artery and venous
anatomy and anatomic variants is important for
correct image interpretation. This anatomy and
the arterial variants have been well described
using conventional angiographic techniques
Keywords: anatomy, anomalies, arteriography, cardiac
[1, 2]. However, the cross-sectional nature of
imaging, coronary arteries, CT angiography, heart, MDCT CT has the benefit of more precisely display-
ing the spatial relationships of coronary arterial
DOI:10.2214/AJR.06.1295 and venous anatomy with respect to cardiac
structures. This article highlights this anatomy
Received September 30, 2006; accepted after revision
January 15, 2007. with a variety of MIP and volume-rendered
techniques (Figs. 1–18).
1Present address: Quantum Medical Radiology, Atlanta,
GA 30339. Subjects and Methods
2Department
Coronary CTA protocols usually image the heart
of Diagnostic Radiology, William Beaumont
Hospital, 3601 W 13 Mile Rd., Royal Oak, MI 48073. Address using cranial-to-caudal acquisition [3]. However,
correspondence to K. G. Bis (kbis@beaumont.edu). caudal-to-cranial scanning acquisitions are imple-
mented when concomitant imaging of the pulmo-
3Present address: Elkhart General Healthcare System, nary arteries is desired in patients with atypical
Elkhart, IN 46514.
chest pain [4]. We describe both of these protocols
CME because the cardiac venous anatomy may be dis-
This article is available for CME credit. See www.arrs.org played with variation in enhancement depending on
for more information. the type of data acquisition.
The patients who participated in our study were
AJR 2007; 188:1665–1674
imaged after the institutional review board had ap-
0361–803X/07/1886–1665
proved the study, which complies with the Health In-
© American Roentgen Ray Society surance Portability and Accountability Act, and after
AJR:188, June 2007
they had provided written informed consent. Patients
were recruited from October 2004 to June 2005.
Imaging was performed on a 64-slice (32-detec-
tor) MDCT scanner (Sensation Cardiac 64, Sie-
mens Medical Solutions) after the patient was pre-
medicated with oral atenolol (50–100 mg), IV
metoprolol (5- to 10-mg boluses, up to 50 mg), or
both. An upper extremity 20-gauge IV catheter was
used for venous access. Sublingual nitroglycerin
(0.4 mg) was provided to induce coronary vasodi-
latation. Bolus timing was measured in the mid as-
cending aorta with 20 mL of iodixanol (320
mgI/mL [Visipaque, GE Healthcare]) administered
at a rate of 5 mL/s followed by a 50-mL saline flush,
also administered at a rate of 5 mL/s). Alternatively,
bolus tracking can be used to trigger data acquisi-
tion by placing a region of interest over the mid as-
cending aorta and setting the trigger threshold to
160 H above baseline.
Single-sector reconstructions of the coronary arter-
ies were performed at 65% and 35% of the R-R length
and were then modified to a different phase start if
there were motion artifacts. Reconstructions were per-
formed on a workstation (Wizard, Siemens Medical
Solutions) and then transferred to another workstation
(TeraRecon, TeraRecon) for MPRs and MIPs.
Cases were selected to show the normal coronary
arterial and venous anatomy. MIPs were obtained us-
ing various thicknesses (5–30 mm) and were dis-
played using standard orientations (right anterior ob-
lique, left anterior oblique, axial) with or without
caudal or cranial angulation. Volume-rendered im-
ages were also obtained using various orientations.
Cranial-to-Caudal Acquisition
Coronary CTA was performed 5 seconds after
aortic peak density; 100 mL of iodixanol (Visi-
paque) was administered at 5 mL/s and was fol-
1665

lowed by a 50-mL saline flush at 5 mL/s [3]. Retro-
spective ECG-gating was used with the following
parameters: collimation, 0.6 mm; tube rotation
time, 0.33 seconds; tube voltage, 120 mV; effective
mAs, 750–850; pitch, 0.2; and scanning time,
10–12 seconds.
Scanning coverage was from the level of the car-
ina to the bottom of the heart. Reconstruction field of
view, slice thickness and reconstruction increment,
and smooth kernel were as follows: 15–22 cm; 0.6
and 0.3 mm, respectively; and B25f. ECG pulsing is
usually implemented for tube current modulation
and is needed to reduce radiation exposure [5].
Caudal-to-Cranial Acquisition
For the caudal-to-cranial acquisition, a patient
preparation and scanning protocol similar to that
described in the previous section was used. How-
ever, contrast injection was performed with a
higher volume of contrast material using a biphasic
protocol: 100 mL of iodixanol was administered at
5 mL/s followed by 30 mL of iodixanol at 3.0 mL/s
and then a 50-mL saline flush at 3 mL/s. The addi-
tional volume of contrast material resulted in a pro-
longed time for contrast injection to ensure ade-
quate enhancement of the pulmonary arteries [4].
As a result, streak artifacts arising from the superior
vena cava and right atrium were present in 37
(88%) of 42 studies; however, these artifacts inter-
fered with the visualization of the right coronary ar-
tery (RCA) in only one (2.4%) of the 42 cases [4].
The thorax from the lung bases to just above
(1–2 cm) the aortic arch was scanned with a 12- to
15-second acquisition (no ECG pulsing), but scan-
ning can include the entire thorax when ECG puls-
ing is applied. As with cranial-to-caudal acquisi-
tions, ECG pulsing is needed to reduce radiation
exposure [5]. Reconstruction field of view, slice
thickness and reconstruction increment, and kernel
for the coronary arteries were similar to those for
the cranial-to-caudal acquisition. However, recon-
structions were also obtained with a larger field of
view [4] to display the pulmonary arteries, thoracic
aorta, lungs, and thoracic soft tissues.
Normal Anatomy of the
Coronary Arteries
The right and left coronary arteries origi-
nate from the right and left sinuses of Valsalva
of the aortic root, respectively. The posterior
sinus rarely gives rise to a coronary artery and
is referred to as the “noncoronary sinus.” The
locations of the sinuses are anatomic misno-
mers: The right sinus is actually anterior in lo-
cation and the left sinus is posterior. The my-
ocardial distribution of the coronary arteries
is somewhat variable, but the right coronary
artery (RCA) almost always supplies the right
1666
Kini et al.
ventricle (RV), and the left coronary artery
(LCA) supplies the anterior portion of the
ventricular septum and anterior wall of the
left ventricle (LV). The vessels that supply the
remainder of the LV vary depending on the
coronary dominance, which we explain later.
RCA Anatomy
The RCA arises from the right coronary si-
nus somewhat inferior to the origin of the
LCA. After its origin from the aorta, the RCA
passes to the right of and posterior to the pul-
monary artery and then emerges from under
the right atrial appendage to travel in the ante-
rior (right) atrioventricular (AV) groove
(Figs. 1 and 2). In about half of the cases, the
conus branch is the first branch of the RCA
(Fig. 3). In the other half, the conus branch has
an origin that is separate from the aorta. The
conus branch always courses anteriorly to sup-
ply the pulmonary outflow tract. Occasionally,
the conus branch can be a branch of the LCA
(Fig. 3D), have a common origin with the
RCA, or have dual or multiple branches.
In 55% of cases, the sinoatrial nodal artery
(Figs. 3C, 3D, and 4A) is the next branch of
the RCA, arising within a few millimeters of
the RCA origin. In the remaining 45% of
cases, the sinoatrial nodal artery arises from
the proximal left circumflex (LCx) artery
(Figs. 4B and 11). In either case, the sinoatrial
nodal artery always courses toward the supe-
rior vena cava inflow near the cephalad aspect
of the interatrial septum. As the RCA travels
within the anterior AV groove, it courses
downward toward the posterior (inferior) in-
terventricular septum. As it does this, the
RCA gives off branches that supply the RV
myocardium; these branches are called “RV
marginals” or “acute marginals” (Fig. 5).
They supply the RV anterior wall. After it
gives off the RV marginals, the RCA contin-
ues around the perimeter of the right heart in
the anterior AV groove and courses toward the
diaphragmatic aspect of the heart.
Coronary Dominance
The artery that supplies the posterior de-
scending artery (PDA) and the posterolateral
branch determines the coronary dominance. If
the PDA and PLB arise from the RCA, then the
system is said to be right dominant (80–85% of
cases) (Figs. 6 and 7). In this instance, the
RCA supplies the inferoseptal and inferior seg-
ments of the LV [6]. If the PDA and PLB arise
from the LCx artery, then the system is said to
be left dominant (15–20% of cases) (Figs. 8
and 17). In this instance, the LCA supplies the
inferoseptal and inferior segments of the LV. If
the PDA comes from the RCA and the PLB
comes from the LCx artery, the system is
codominant (about 5% of cases) (Fig. 9).
In left-dominant and codominant systems,
the LCx artery continues in the posterior AV
groove as the left AV groove artery and gives
rise to left PLB. In left dominance, the PDA is
the final branch of the AV groove artery. The
distal RCA divides into the PDA and PLB in
a right-dominant system. The nondominant
system is usually noticeably smaller in caliber
than the dominant system. This difference in
caliber can be used as an additional clue to de-
termine whether the coronary anatomy is
right or left dominant. Usually arising just
distal to the origin of the PDA, the AV nodal
artery (Fig. 6) can be recognized by its direct
vertical course off of the distal RCA. In cases
of left dominance, the AV node branch has a
similar appearance and location, but it arises
just proximal to the (left) PDA.
LCA Anatomy
The LCA normally emerges from the left
coronary sinus as the left main (LM) coronary
artery (Fig. 10). The LM coronary artery is
short (5–10 mm), passes to the left of and pos-
terior to the pulmonary trunk, and bifurcates
into the left anterior descending (LAD) and
LCx arteries (Fig. 11). Occasionally, the LM
coronary artery trifurcates into the LAD ar-
tery, the LCx artery, and the ramus interme-
dius artery (Fig. 12).
Ramus Intermedius Artery
The most common variation in LCA anat-
omy is the presence of a trifurcation of the LM
coronary artery. In this instance, the LM coro-
nary artery trifurcates into the LAD artery, LCx
arteries, and an artery between them called the
“ramus intermedius” artery (Fig. 12). The ra-
mus intermedius artery itself has variable
branching. The ramus intermedius can be dis-
tributed as a diagonal branch or as an obtuse
marginal branch depending on whether it sup-
plies the anterior or the lateral wall, respectively.
LAD Artery
The LAD artery (Fig. 13) runs in the ante-
rior interventricular sulcus along the ventricu-
lar septum. Commonly, the LAD artery may be
embedded within the anterior myocardium
forming an overlying myocardial bridge
(Fig. 14). Myocardial bridging is seen more of-
ten on CT than described in the coronary an-
giography literature. Most myocardial bridges
are asymptomatic, although rarely myocardial
AJR:188, June 2007
 CT Angiography of Coronary Arterial and Venous Anatomy
bridging can be associated with ischemia. The
LAD artery has branches called “septal perfo-
rators” (Fig. 14) that supply the anterior ven-
tricular septum. It also has diagonal arteries
(Fig. 15) that course over and supply the ante-
rior wall of the LV. The diagonals and septal
perforators are numbered sequentially from
proximal to distal (i.e., D1, D2, S1, S2).
LCx Artery
The LCx artery (Figs. 16, 17, and 2, 4B, 8,
11, 12, 15) runs in the posterior AV groove anal-
ogous to the course of the RCA on the opposite
side. The major branches of the LCx artery con-
sist of obtuse marginals (OMs) (Figs. 16 and
17). OM branches supply the lateral wall of the
LV. They are numbered sequentially from prox-
imal to distal (i.e., OM1, OM2, OM3).
Anomalies of RCA Origin
The RCA can have an anomalous origin. It
is important to be aware of this possibility to
avoid misinterpreting coronary CTA. Typi-
cally, the anomalous origin of the RCA is
from the left coronary sinus of Valsalva, with
a subsequent course between the aortic root
and right ventricular outflow tract. Depiction
of these anomalies is beyond the scope of this
article; however, this and other anomalies of
RCA origin are described by Kim et al. [7].
An example of an anomalous origin of the
RCA is shown in Figure 18.
Anomalies of LCA Origin
The LCA and its branches can have an
anomalous origin. It is important to be aware
of this possibility to avoid misinterpreting
coronary CTA. Some of these anomalies are
associated with an increased risk of sudden
death or cardiac arrest (Fig. 18C). Depiction
of these anomalies is beyond the scope of this
article; however, anomalies of LM, LAD, and
LCx origin are reviewed by Kim et al. [7].
Coronary Venous Anatomy
The great cardiac vein (Figs. 4B and
16A) is located in the anterior interventric-
ular sulcus, alongside the LAD artery. It
courses upward from the apex and drains
into the coronary sinus. The middle cardiac
AJR:188, June 2007
vein (Figs. 7A and 7C) also begins at the
apex, but it courses upward in the inferior
interventricular sulcus, alongside the PDA.
Between the two, there is a variable poster-
olateral vein (Fig. 7C) draining the lateral
wall of the LV. The coronary sinus
(Figs. 7A, 7C, 16A, and 16B) is the wide
vein that courses in the posterior AV groove
accompanying the LCx artery and the AV
groove artery. It drains into the right atrium
and receives the great cardiac vein proxi-
mally and the middle cardiac vein distally.
Reporting System of
Coronary Artery Disease
In an attempt to standardize the reporting
of coronary artery disease, an ad hoc commit-
tee of the American Heart Association devel-
oped nomenclature and further divided the
main coronary arteries into proximal, middle,
and distal segments [8].
The proximal RCA segment is from the
ostium to one half the distance to the acute
margin of the heart. The middle RCA seg-
ment is the RCA from the end of the above
segment to the acute margin of heart. The
distal RCA segment is the RCA running
along the right AV groove from the acute
margin to the origin of the PDA.
The LAD proximal segment is proximal
to and includes the origin of the first major
septal perforator. The middle LAD segment
is the LAD artery immediately distal to the
origin of the first major septal perforator
that extends to the point where the LAD ar-
tery forms an angle (right anterior oblique
view). This angle is often, but not always,
close to the origin of the second diagonal. If
this angle or diagonal is not identifiable, this
segment ends one half the distance from the
first major septal perforator to the apex. The
apical LAD segment is the terminal portion
of the LAD artery that begins at the end of
the previous segment and extends to or be-
yond the apex.
The proximal LCx segment is the main-
stem of the LCx artery from its origin off the
LCA to and including the origin of an obtuse
marginal. The distal LCx segment is the LCx
artery distal to the origin of the obtuse mar-
ginal and travels along or close to the poste-
rior AV groove.
Conclusion
Coronary CTA is emerging as an essential
imaging tool for evaluating the coronary ar-
teries. Knowledge of the CT appearance of
the coronary anatomy and various coronary
artery anomalies is essential for accurate di-
agnosis and proper patient treatment.
References
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2. Soto B, Russell RO, Moraski RE. Radiography
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3. Raff GL, Gallagher MJ, O’Neil WW, Goldstein JA.
Diagnostic accuracy of noninvasive coronary an-
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4. Vrachliotis TG, Bis KG, Hardary A, et al. Enhance-
ment of coronary, aortic and pulmonary vasculature
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5. Jakobs TF, Becker CR, Ohnesorge B, et al. Mul-
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6. Cerqueira MD, Weisman NJ, Dilsizian V, et al.
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7. Kim SY, Seo JB, Do KH, et al. Coronary artery
anomalies: classification and ECG-gated multi-de-
tector row CT findings with angiographic correla-
tion. RadioGraphics 2006; 26:317–334
8. Austen WG, Edwards JE, Frye RL, et al. A report-
ing system on patients evaluated for coronary artery
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ing of Coronary Artery Disease, Council on Car-
diovascular Surgery, American Heart Association.
Circulation 1975; 51[suppl 4]:5–40
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 Kini et al.

Fig. 1—Anterior schematic diagram of heart shows course of dominant right

coronary artery and its tributaries. AV = atrioventricular, PDA = posterior
descending artery, RCA = right coronary artery, RV = right ventricular,
SA = sinoatrial.

A B
Fig. 2—CT images of normal heart in 53-year-old man.
Ao = aortic root, CS = coronary sinus, LA = left atrium,
LAD = left anterior descending artery, LCx = left
circumflex artery, LM = left main coronary artery,
LV = left ventricle, PDA = posterior descending artery,
RA = right atrium, RCA = right coronary artery, RV = right
ventricle, RVOT = right ventricular outflow tract.
A, Axial 5-mm maximum-intensity-projection (MIP)
image shows left main coronary artery as it arises from
left coronary cusp.
B, Axial 5-mm MIP image shows right coronary artery
as it arises from right coronary cusp inferior to level of
beginning of left main coronary artery.
C, Axial 5-mm MIP image shows course of right
coronary artery within anterior atrioventricular groove.
Left anterior descending artery is shown within
anterior interventricular groove, and left circumflex
artery is shown in posterior atrioventricular groove.
D, Axial 5-mm MIP image shows origin of posterior
descending artery from distal right coronary artery.
C D

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 CT Angiography of Coronary Arterial and Venous Anatomy

Fig. 3—Conus branch anatomy variations. Ao = aortic

root, LA = left atrium, LAD = left anterior descending
artery, LM = left main coronary artery, LV = left
ventricle, RA = right atrium, RCA = right coronary
artery, RVOT = right ventricular outflow tract,
SAN = sinoatrial node branch.
A, Left anterior oblique 5-mm maximum-intensity-
projection (MIP) image shows conus branch (arrow) in
44-year-old woman as it arises separate from right
coronary artery off of right coronary cusp.
B, Left anterior oblique 15-mm MIP image shows
common origin of conus branch (arrow) and right
coronary artery in 40-year-old man.
C, Axial 10-mm MIP image shows conus branch
(arrow) arising from proximal RCA in 52-year-old man.
It then courses anteriorly toward right ventricular
outflow tract.
D, Axial 10-mm MIP image shows conus branch
(arrow) arising from left anterior descending artery in
46-year-old man.
A B

C D

Fig. 4—Sinoatrial node branch variations. Ao = aortic

root, D1 = first diagonal, GCV = great cardiac vein,
LA = left atrium, LAD = left anterior descending artery,
LCx = left circumflex artery, LM = left main coronary
artery, OM1 = first obtuse marginal, RCA = right
coronary artery, RVOT = right ventricular outflow tract,
SVC = superior vena cava.
A, Axial 10-mm maximum-intensity-projection (MIP)
image in 64-year-old man shows large sinoatrial node
branch (arrow) as it arises from proximal right
coronary artery. It then courses posteriorly toward
cephalad aspect of interatrial septum (arrowheads)
posterior to inflow of superior vena cava.
B, Axial 10-mm MIP image shows sinoatrial node
branch (arrow) in 65-year-old woman as it arises from
proximal left circumflex artery: Sinoatrial branch still
courses toward cephalad aspect of interatrial septum.
A B

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 Kini et al.

A B
Fig. 5—Marginal branch anatomy. F = foot, LAD = left anterior descending artery, LV = left ventricle, RCA = right Fig. 6—Distal right coronary artery anatomy in 34-year-
coronary artery, RV = right ventricle. old man. Left anterior oblique 20-mm maximum-
A, Right anterior oblique 10-mm maximum-intensity-projection (MIP) image shows large marginal branch (arrow) intensity-projection image shows course of entire right
arising from right coronary artery (RCA) in 40-year-old woman. coronary artery. Distally, posterior descending artery
B, Right anterior oblique volume-rendered image shows marginal branch (arrow) of RCA as it courses over right and posterior lateral branch are shown, as is
ventricle in 45-year-old woman. atrioventricular node branch. Ao = aortic root,
AVN = atrioventricular node, IMB = inferior marginal
branch, LCx = left circumflex artery, LV = left ventricle,
PDA = posterior descending artery, PLB = posterior
lateral branch, RCA = right coronary artery,
RVOT = right ventricular outflow tract.

A B C
Fig. 7—Distal dominant right coronary artery variation on axial projections. CS = coronary sinus, LV = left ventricle, MCV = middle cardiac vein, PDA = posterior descending
artery, PLB = posterior lateral branch, PLV = posterolateral vein, RA = right atrium, RCA = right coronary artery, RV = right ventricle.
A, Axial 10-mm maximum-intensity-projection (MIP) image in 51-year-old man shows typical tortuous course of posterior descending artery as it arises from distal right
coronary artery. Posterior descending artery travels in inferior interventricular groove along side middle cardiac vein. Posterior lateral branch continues along distal coronary
sinus to supply inferior wall.
B, Axial 10-mm MIP image shows dual posterior descending arteries and dual posterior lateral branches in 44-year-old man.
C, Axial 3D volume-rendered projection image shows origin of posterior descending artery, which still courses toward middle cardiac vein, is higher than normal in 49-year-
old woman.

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 CT Angiography of Coronary Arterial and Venous Anatomy

A B C
Fig. 8—Dominant left circumflex artery and posterior descending artery anatomy. Ao = aortic root, AVGA = atrioventricular groove artery, CS = coronary sinus, LA = left
atrium, OM = obtuse marginal, PDA = posterior descending artery, PLB = posterior lateral branch, RA = right atrium, RCA = right coronary artery.
A and B, Left anterior oblique 10-mm maximum-intensity-projection (MIP) images show two examples of dominant left circumflex artery anatomy with typical small nature
of right coronary artery: one in 43-year-old woman (A) and one in 44-year-old man (B). Atrioventricular groove artery descends as larger-caliber artery in posterior
atrioventricular groove subjacent to coronary sinus.
C, Axial 10-mm MIP image shows dual posterior descending arteries as they arise from distal atrioventricular groove artery in 44-year-old man with dominant left circumflex artery.

Fig. 10—Dominant left

coronary artery anatomy.
Left anterior oblique
schematic diagram of
dominant left coronary
Fig. 9—Codominance. Axial 10-mm maximum- artery anatomy, including
intensity-projection image reveals codominant left anterior descending
anatomy in which posterior descending artery arises artery and left circumflex
from right coronary artery and posterior lateral branch artery tributaries,
arises from distal left circumflex artery in 33-year-old is shown. AVGA =
man. LV = left ventricle, PDA = posterior descending atrioventricular groove
artery, PLB = posterior lateral branch, RCA = right artery, PDA = posterior
coronary artery, RV = right ventricle. descending artery.

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 Kini et al.

Fig. 11—Left main coronary artery bifurcation. Anterior

caudal 10-mm maximum-intensity-projection image
displays typical bifurcation of left main coronary artery
into left anterior descending and left circumflex
arteries in 47-year-old man. AVGA = atrioventricular
groove artery, D1 = first diagonal, LAD = left anterior
descending artery, LCx = left circumflex artery,
LM = left main coronary artery, OM1 = first obtuse
marginal, SAN = sinoatrial node branch.

A B C
Fig. 12—Ramus intermedius anatomy. LAD = left anterior descending artery, LCx = left circumflex artery, LM = left main coronary artery, RI = ramus intermedius artery.
A, Right anterior oblique caudal 10-mm maximum-intensity-projection (MIP) image displays trifurcation of left main coronary artery into left anterior descending artery, ramus
intermedius artery, and left circumflex artery in 49-year-old man.
B, Axial 10-mm MIP image shows left main coronary artery dividing into left anterior descending artery, left circumflex artery, and ramus intermedius branches in 42-year-
old woman.
C, Left posterior cranial 3D volume-rendered projection image shows branching ramus intermedius artery, which is mostly distributed as obtuse marginal branch to lateral
wall, in 52-year-old man.

Fig. 13—Left anterior descending artery course. Right

anterior oblique 10-mm maximum-intensity-projection
image reveals entire course of left anterior descending
artery within anterior interventricular groove in 44-
year-old woman. Distally, it is seen wrapping around
left ventricular apex (arrows). LA = left atrium,
LV = left ventricle.

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 CT Angiography of Coronary Arterial and Venous Anatomy

Fig. 14—Myocardial bridge and septal perforator

branch anatomy in 39-year-old woman. LA = left
atrium, LAA = left atrial appendage, LV = left ventricle,
S1, S2, S3 = first, second, and third septal perforators.
A, Right anterior oblique 10-mm maximum-intensity-
projection (MIP) image displays left anterior
descending artery and septal perforator branches.
Myocardial bridge overlies left anterior descending
artery just beyond second septal perforator (arrows).
B, Short-axis (left anterior oblique) 5-mm MIP image at
level of myocardial bridge shows left anterior
descending artery (arrow) deep to right ventricular
myocardium junction with left ventricle.

A B

Fig. 15—Diagonal branch anatomy. D1 = first diagonal,

D2 = second diagonal, LAD = left anterior descending
artery, LCx = left circumflex artery, LM = left main
coronary artery, LV = left ventricle, RI = ramus
intermedius artery, SP = septal perforator branches.
A, Axial caudal oblique 10-mm maximum-intensity-
projection (MIP) image reveals two diagonal branches
(D1 and D2) from left anterior descending artery in 55-
year-old man. Diagonal branches course laterally, and
small septal perforator branches course medially.
B, Cranial left anterior oblique 10-mm MIP image
shows left anterior descending artery and two
diagonal branches in 47-year-old man.

A B

Fig. 16—Nondominant left circumflex artery anatomy

in 36-year-old man. AVGA = atrioventricular groove
artery, CS = coronary sinus, D1 = first diagonal,
GCV = great cardiac vein, LAD = left anterior
descending artery, LCx = left circumflex artery,
OM1 = first obtuse marginal.
A, Axial 10-mm maximum-intensity-projection (MIP)
image shows left circumflex artery and left anterior
descending artery with large first obtuse marginal
arising from proximal left circumflex artery. Small left
circumflex artery descends in posterior atrioventricular
groove as atrioventricular groove artery.
B, Left anterior oblique 10-mm MIP image displays left
circumflex artery anatomy with its descent as
atrioventricular groove artery.
A B

AJR:188, June 2007 1673

 Kini et al.

Fig. 17—Dominant left circumflex artery anatomy in

44-year-old man. AVGA = atrioventricular groove
artery, LCx = left circumflex artery, LM = left main
coronary artery, OM1 = first obtuse marginal,
OM2 = second obtuse marginal, PDA = posterior
descending artery, PLB = posterior lateral branch,
RI = ramus intermedius artery.
A, Left anterior oblique cranial 3D volume-rendered
image shows dominant left circumflex artery anatomy
with two obtuse marginal branches.
B, Axial 3D volume-rendered image reveals dual
posterior descending artery and posterior lateral branch
arising from distal atrioventricular groove artery.

A B

A B C
Fig. 18—Anomalous origin of right coronary artery and left main coronary artery. Ao = aortic root, LAD = left anterior descending artery, LM = left main coronary artery,
RCA = right coronary artery, RVOT = right ventricular outflow tract.
A, Axial 5-mm maximum-intensity-projection (MIP) image shows anomalous origin of right coronary artery in 43-year-old woman from anterior proximal ascending aorta with
subsequent acute rightward course before reaching anterior atrioventricular groove.
B, Three-dimensional volume-rendered projection image shows anomalous right coronary artery in same patient as A above level of right coronary cusp (arrow).
C, Axial 10-mm MIP image reveals anomalous origin of left main coronary artery in 35-year-old man from right cusp near origin of right coronary artery. It then takes intraseptal
course posterior to right ventricular outflow tract near cephalad aspect of interventricular septum.

F O R YO U R I N F O R M AT I O N

This article is available for CME credit. See www.arrs.org for more information.

1674 AJR:188, June 2007