case_images: PMC11127586_01
case_images: ECG in the emergency department demonstrating displayed sinus rhythm, incomplete right bundle branch block, and ST-segment elevation in leads II, III, AVF, with poor R-wave progression in leads V1-V6. ECG, electrocardiography.
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case_images: F1
case_images: The electrocardiogram (ECG) (Figure 1) displayed sinus rhythm, incomplete right bundle branch block, and mild ST-segment elevation in leads II, III, AVF, with poor R-wave progression in leads V1-V6.
case_images: The initial emergency coronary angiography during the first hospitalization: (A) left coronary angiography revealed complete occlusion of the proximal left anterior descending artery (LAD) after the origin of the diagonal branch, with no residual segment observed. The left circumflex artery appeared small, and no significant stenosis was observed. (B) Right coronary angiography showed diffuse and severe lesions throughout the entire length of the right coronary artery (RCA) with moderate to severe calcification. The distal segment presented total occlusion with a high thrombus burden, and a suspicious vessel shadow was noted below the ostium of the RCA. (C) A rare finding was observed where a branch similar to the left circumflex artery arose approximately 1-2 cm below the origin of the right coronary artery, also originating from the right sinus. There were scattered plaques in the proximal and mid segments of this branch, with an eccentric stenosis of approximately 90% at the bifurcation. We refer to this vessel as the right circumflex artery (RCX). (D) Right coronary artery emergency PCI images indicated resolution of vessel occlusion, absence of residual stenosis, and restoration of blood flow to TIMI 3 levels.
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case_images: F2
case_images: Upon admission, emergency coronary angiography was immediately performed using a 5F angiographic catheter (Figures 2A-C), revealing a tri-ostial anomaly in the coronary arteries. The final angiography showed satisfactory stent apposition with no dissection, and TIMI 3 flow was successfully restored (Figure 2D).
case_images: The coronary artery anomalies and sites of obstructive lesions are described in the central illustration.
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case_images: F3
case_images: The coronary artery anomalies and sites of obstructive lesions are described in the Central Illustration (Figure 3).
case_images: The second hospitalization coronary angiography: (A,B) the left anterior descending artery and left circumflex artery also exhibit dual openings. (C) Further confirmation reveals dual openings of the right coronary artery and right circumflex artery at the right coronary sinus.
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case_images: F4
case_images: One month later, a subsequent coronary angiography (Figures 4A,B) was conducted using a 5F angiographic catheter, revealing a coronary artery quadrifurcation anomaly. Angiography after the procedure (Figure 4C) showed no residual stenosis or dissection, and forward blood flow was successfully restored with TIMI 3.
case_images: Intraoperative and postoperative intravascular ultrasound (IVUS) images, as well as coronary angiography: (A) after pre-dilation, IVUS revealed a large intramural hematoma. (B) Final angiography of the left anterior descending artery showed satisfactory apposition of the stent to the vessel wall, with no signs of dissection, and forward blood flow rated as TIMI3. (C) Intravascular ultrasound demonstrated that the stent in the left anterior descending artery extended into the left main trunk, further confirming the presence of a common origin of the left anterior descending and left circumflex arteries with the left main coronary artery measuring approximately 1 mm in length.
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case_images: F5
case_images: IVUS examination (Figure 5A) showed a hematoma in the near segment. Postoperative coronary angiography (Figure 5B) and IVUS (Figure 5C) confirmed satisfactory stent expansion with no dissection, and the stent protruded into the left main stem by approximately 1 mm.