case_images: PMC9632949_01
case_images: Coronary angiography of the right coronary artery (RCA). The yellow arrow is pointing the right coronary ostium originating from the left coronary sinus.
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case_images: PMC9632949_01_fcvm-09-975014-g001.jpg
case_images: F1
case_images: Surprisingly, an R-ACAOS was also found (Figure 1).
case_images: (A) Volume rendering and (B) maximum intensity projection reformations demonstrating an anomalous origin of the right coronary artery from the left coronary sinus and an its intramural and interarterial course (red arrows). (C) Coronal oblique image shows an "elliptic shape" (red circle) of the interarterial course of the right coronary artery (high-risk feature). Ao, Aorta. PA, Pulmonary Artery.
case_images: fcvm-09-975014-g002.jpg
case_images: PMC9632949_01_fcvm-09-975014-g002.jpg
case_images: F2
case_images: A CT coronary angiogram confirmed the origin of the right coronary artery (RCA) from the left sinus of Valsalva, with an intramural course and a malignant path between the aorta and the pulmonary artery (Figure 2).
case_images: Transit time flow measurement of the RIMA-RCA bypass graft before (A) and after (B) proximal right coronary artery ligation. RIMA, right internal mammary artery; RCA, right coronary artery.
case_images: fcvm-09-975014-g003.jpg
case_images: PMC9632949_01_fcvm-09-975014-g003.jpg
case_images: F3
case_images: After completing the anastomosis, transit time flowmetry (TTFM) showed a poor graft flow (6 mL/min with a pulsatility index (PI) of 2.0), indicating a competitive flow with the native RCA (Figure 3). At a graft flow of 20 mL/min with a PI of 0.7, the RCA was proximally ligated (Figure 3).