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O riginal A rticle
Variant Anatomy of Coronary Arteries
Jyoti P Kulkarni
Department of Anatomy, Dr. D.Y. Patil Medical College, Pimpri, Pune, Maharashtra, India
ABSTRACT

Introduction: Wide variations exist in the size, position, and shape of various body organs, finger prints, and proteins in
different individuals. Some variations are of considerable clinical importance, such as the coronary arteries. Variations
of coronary arteries can cause important clinical manifestation, including sudden death of the individual. Materials and
Methods: Coronary arteries were dissected in 10% formalin-fixed cadaveric hearts. The normal and variant anatomy of
coronary arteries was studied. Result: In 100% of cases, the right coronary artery (RCA) and main left coronary artery (LCA)
were found to arise from anterior aortic sinus and left posterior aortic sinus, respectively. In 8% of cases, the conus was found
to have independent origin from the anterior aortic sinus. The RCA was found to be dominant in 90% of cases. In 66.7% of
cases, the length of RCA ranged from 4.5 cm to 7 cm. The average length of LCA was found to be 7 mm. In 10% of cases, the
circumflex coronary artery was found to be dominant, where the length of the artery ranged 9-11 cm. In 10% of cases, LCA
trifurcated, where the obtuse marginal branch was replaced by the ramus intermedius branch. Also, 43.3% of LAD showed
myocardial bridging predominantly in the middle 1/3rd segment, and 6.7% of cases of RCA showed myocardial looping.
Discussion: Coronary arteries show immense variation in their origin, termination, branching pattern, myocardial bridging,
looping, and dominance pattern. This knowledge is clinically and surgically important to manage coronary artery diseases.

Key words: Left coronary artery, looping, myocardial bridging, ramus intermedius, right coronary artery
INTRODUCTION

MATERIALS AND METHODS

Coronary arteries are the greatly enlarged vasa vasora, which

supply blood to the heart in the form of ring and sling. The
right and the left coronary arteries arise from the aortic sinus
of valsalva at the root of the aorta and encircle the base of
ventricles like a crown. Variations of coronary arteries can be
fatal. It can lead to sudden death during strenuous activity. A
cadaveric study in unsuspected population can help understand
the variations that will be useful to determine the prevalence
of certain variations.

A detailed dissection of coronary arteries in 60 cadaver hearts

fixed in 10% formalin was carried out in the Department
of Anatomy. The coronary arteries and their branches were
dissected in the atrioventricular and interventricular grooves
on the surface of heart. Origin, branching pattern, dominance,
length, myocardial bridging, and looping of the arteries was
studied. The length of the arteries was measured with the help
of thread and millimeter scale.

Address for correspondence:

In all 60 cases, the dissected right coronary artery (RCA)

was found to arise from the anterior aortic sinus [Table 1a].
In 65% of cases, where the range of length of RCA was
around 8-14 cm, the artery was dominant, i.e., the posterior
descending (PD) branch and branch to AV node was found
to be a branch of RCA [Figure 1] [Table 3]. The branch to
SA node in all the cases was found to be a branch from RCA
[Figure 2] [Table 1b]. The conus was found to arise from RCA
in 92% of cases [Figures 2 and 3]. However, in 8% of cases,
the conus had an independent origin from the anterior aortic
sinus [Figure 4] [Table 1a]. The acute marginal branch arose
from the RCA at the right border of heart. The range of length
of this branch was found to be 3-4.5 cm in 23%, 4.5-7 cm in

Dr. Jyoti P Kulkarni,

Flat No. 6, Oriental Heritage, Manik Colony,
Tanaji Nagar, Chinchwad, Pune - 411 033,
Maharashtra, India.
E-mail: jyopidhut@gmail.com
Access this article online
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Website:
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DOI:
10.4103/2321-449x.118582

46

RESULTS

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Kulkarni: Coronary artery variations

Figure 1: (a) Myocardial looping around the RCA, (b) Posterior

ventricular branch of RCA, (c) Branch to AV node

Figure 2: Right coronary artery: (a) Branch to SA node, (b) Conus

branch, (c) Myocardial looping around the right coronary artery

Figure 3: (a) Conus branch of RCA, (b) Myocardial bridge over the
branch of RCA (a)

Figure 4: (a) Right coronary artery, (b) Conus independent origin

Table 1a: Variation in the origin

Site of Origin
AAS
LPAS

Figure 5: (a) Left coronary artery, (b) Left anterior interventricular

artery, (c) Ramus intermedius, (d) Circumflex coronary artery

66.7%, and 7-10 cm in 10% of cases [Table 3]. PD artery and

artery to AVN was found to be a branch of RCA in 90% and
branch of circumflex in 10% of cases. In 60% of cases, the
length of PD artery was found to be in the range of 5-7.5cm

LCA

RCA
60 (100%)

Right conus
5 (8%)

60 (100%)

[Table 4]. In all 60 cases, the dissected left coronary artery

(LCA) was found to originate from the left posterior aortic
sinus of the ascending aorta. The average length of LCA was
found to be 7 mm, after which, it bifurcated or trifurcated
[Tables 1a, 1b, 2] In 16.6% of cases, the LCA trifurcated into
left anterior descending (LAD), circumflex (CX), and ramus
intermedius (RI) branch [Figure 5], while, in 83.3% of cases, it
bifurcated into LAD and CX branch. In all 60 cases, the LAD
and CX were found to be the branches of LCA. The length
of CX was found to be 3-5 cm in 20%, 5-9 cm in 70%, and
9-11 cm in 10% of all cases. In these, 10% of cases with the
maximum length of the circumflex coronary artery was found
to be dominant, i.e., the PD and branch to AVN were found
to be the branches of CX coronary artery. The length of LAD
was seen to be 4-7 cm in 3%, 7-10 cm in 16.6%, 11-14 cm

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Kulkarni: Coronary artery variations

in 66.6%, and 14-17 cm in 13.33% of all cases. In the range

of length from 10 cm to 17 cm, the LAD was found to turn
around the apex of the heart and anastomose with PD branch.
Along its length, the LAD gave rise to 2-3 diagonal branches
on its left side. The obtuse marginal artery was found to be a
branch of circumflex coronary artery in all 60 cases. However,
in 10 cases where the LCA trifurcated, the OM was replaced
by the RI branch of LCA [Figure 5] [Table 2].

DISCUSSION

In 6.7% of cases, the RCA showed myocardial looping [Figures 1

and 2] and, in another 6.7% of cases, the PD showed myocardial
bridging [Table 5]. The myocardial bridging was seen in LAD in
43.3% of cases [Figure 6], while circumflex showed myocardial
looping in 16.7% of cases [Figure 7]. The myocardial bridging
was seen predominantly in the middle 1/3rd segment of the LAD
in 26.7% of cases [Figure 6] [Table 6].

The RCA, after arising from the anterior aortic sinus, usually
gives the following branches: Branch to SA node, conus, acute
marginal, PD, and branch to AV node. PD branch gives septal
branches to the posterior 1/3rd of interventricular septum.
The LCA usually bifurcates into LAD and circumflex coronary
artery. The LAD gives septal branches to the anterior 2/3rd of
interventricular septum. It also gives 2-3 diagonal branches on the
sternocostal surface. The circumflex coronary artery gives obtuse
marginal branch and ends at the crux of the heart by giving PD
branch and branch to AV node. The PD and branch to AV node
decides the dominance of coronary arteries. If it is a branch of
the right coronary, it is called as right-dominant circulation. If it
is a branch of CX, then it is said to be left-dominant circulation.
Codominance may also exist. Usually, the coronaries lie on the

Figure 6: (a) Myocardial bridging over the left anterior interventricular

artery, (b and c) Diagonal branches.

Figure 7: (a) Myocardial looping around circumflex, (b) Anastomosing

branch of CX to RCA, (c) Right coronary artery, (d) Posterior
interventricular artery, (e) Branch to AV node

Table 1b: Variation in the branching pattern

Branch
of

LCA

LAD

CX

RI

60
(100%)

60
(100%)

10
(16.6%)

RCA
CX
LAD

OM

Diagonals

PD

AVN

Right
conus

Left
conus

SAN

AM

2 (3.3%)
54 (90%) 54 (90%) 55 (91.6%)
06 (10%) 06 (10%)

50 (83.3%)

60 (100%) 60 (100%)

60 (100%)

LCA: Left coronary artery, LAD: Left anterior descending or Left anterior interventricular artery, CX: Circumflex coronary artery, RI: Ramus intermedius branch, RCA: Right
coronary artery, PD: Posterior descending or posterior interventricular artery, AVN: Branch to AV node, SAN: Branch to sinoatrial node, OM: Obtuse marginal branch,
AM: Acute marginal branch

Table 2: Left coronary artery system length, dominance, and termination

Length of
LCA (mm)

5 mm
7 mm
10 mm

48

No. of cases

Length of
LAD

No. of cases

Trifurcation
of LCA

Bifurcation
of LCA

Length of
CX (cm)

No. of cases

Dominance

46 (76.7%)
11(18.3%)
3 (5%)

4-7 cm
7-10 cm
11-14 cm
14-17 cm

2 (3.3%)
10 (16.6%)
40 (66.66%)
08 (13.33%)

10 (16.6%)

50 (83.3%)

3-5 cm
5-9 cm
9-11 cm

12 (20%)
42 (70%)
06 (10%)

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Kulkarni: Coronary artery variations

Table 3: Right coronary artery length and dominance

Length of
RCA (cm)

No. of
cases

6-8 cm
8-14 cm
14-17 cm

8 (13.33%)
39 (65%)
03 (5%)

Dominance Length
of AM

+
+

3-4.5
4.5-7
7-10

No. of cases

14 (23.33%)
40 (66.66%)
06 (10%)

Table 4: Posterior descending branch length

Branch of

No. of cases

Length (cm)

No. of cases

Circumflex
RCA

06 (10%)
54 (90%)

3-5
5.1-7.5
7.6-9

21 (35%)
36 (60%)
3 (5%)

Table 5: Myocardial bridging and looping of right

and left coronary arteries
Artery

Myocardial bridging
No. of cases

LAD
Cx
RCA
AM
PD
OM

Looping No. of cases

26 (43.33%)

3 (5%)
4 (6.66%)
6 (10%)

10 (16.66%)
04 (6.66%)

Table 6: Myocardial bridging in LAD territory

Myocardial bridging

No. of cases

Proximal 1/3
Middle 1/3
Proximal+Middle 1/3
Middle+Distal 1/3
Distal 1/3

2
16
1
5
2

3.33
26.66
1.6
8.33
3.33

myocardial surface. Occasionally, the myocardium may cover

a segment of branches of coronary arteries; these are called
as myocardial bridges. When the coronary arteries run in an
atriventricular groove, the atrial musculature may loop around
the arteries; these are called as myocardial loops. However,
the coronary arteries showed a considerable variation in the
branching pattern, length, and myocardial bridging. According to
Loukas et al., (2009),[1] it is desirable to determine the incidence
of variations that are potentially capable of producing sudden
cardiac death. In the present study, the prevalence of independent
origin of the right conus from the anterior aortic sinus was 8%,
wherein it showed the presence of an accessory ostium in the
anterior aortic sinus. This ostium was relatively smaller in size
and was situated higher to that for the RCA. In 1967, Baroldi
and Scomazzoni[2] described the prevalence of independent
origin of right conus to be about 36%. Similar findings were
noted by Bhimalli et al.,.[3] Since the accessory ostium is very
small, it may fail to get opacified during angiographic procedures.
In all 60 cases, the RCA arose from the anterior aortic sinus.
However, RCA may have ectopic origin from the LPAS. The

prevalence of this ectopic origin was observed to be 0.0008% on

angiographic studies, as mentioned by Yarnanaka and Hobbs[4]
and 0.043-0.46%, as studied by Solanki et al.[5] Simkoff (1982)[6]
reported a case of anomalous origin of RCA from the LAD.
Multiple attempts to cannulate this artery were unsuccessful and
an aortic flush injection confirmed its absence.
In the present study, the branch to SA node was seen to arise from
the RCA in all 60 cases. However, in 1978, Hutchison[2] described a
variable origin of the branch to SA node from circumflex coronary
artery in 35% of cases, which is a significant fact. In 1961, James[2]
described the course of main LCA, wherein he stated that the
branch to SA node may arise from the LCA. Kini et al.,[7] found
that the branch to SA node arose as the branch of RCA in 55%
of cases on computed tomography (CT) angiograms.
In the present study, in 90% of the cases, the RCA was
dominant, i.e., the branch to AV node and PD branch is a
branch of RCA in 90% of the cases. A dominant right coronary
terminates beyond the crux by giving 2-3 posterior lateral
ventricular branches. In 60% of the hearts, the RCA reaches
the crux and terminates a little to the left of crux in a variable
degree of anastomosis with the circumflex branch of the LCA.
In 10% of the cases, it ends near the right cardiac margin or
between this and the crux and, in 20% of the cases, it may
even reach the left border of the heart, replacing the terminal
part of circumflex. The range of length was 8-14 cm in 65%
of cases, where the artery was dominant.
The LCA, which usually arises from LPAS, terminates by
bifurcation into LAD and circumflex coronary artery. However,
in the present study, it trifurcates in 16% of the cases, thus giving
rise to RI branch that runs along the obtuse margin of the heart.
However, the prevalence of occurrence of RI is 35-50%.[2] The
incidence of ectopic origin of the circumflex from the right sinus
of valsalva is reported to be 1.6-1.2%.[8] In a study by Demetrios,
it was found to be 0.64%.[8] Calvalcanti (1995) observed that,
in 1.82% of the cases, the CX and LAD arose directly from
the ascending aorta.[9] In the present study, the length of LCA
was found to be 5 mm in 76.7% of cases, while it was found to
be 10 mm in 5% of cases. Waller et al.,[10] found the length of
LCA to be 6 mm in 76% of all cases and 10 mm in 3% of all
cases. Davies et al., quoted the length of LCA to be <6 mm in
36% of all cases and >20 mm in 5% of all cases on cine angio
films. In early bifurcation of LCA, the coronary cannula may
selectively perfuse one main branch and occlude the others.[11]
Short length of LCA may be a predisposing factor to coronary
artery disease.[12]
In the present study, the circumflex coronary artery dominated in
10% of the cases. The origin of PD and the branch to AV node
decided the dominance pattern. Mian et al., found circumflex
to be dominant in 19.5% of the cases, while they found codominance in 20% of the cases.[13] Reddy found the circumflex

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Kulkarni: Coronary artery variations

to be dominant in 11.26% of all cases and codominance in 2.5%

of all cases.[14]
In the present study, the branch to SA node arose as a branch from
RCA in 100% of cases. However, it may arise from circumflex,
usually from its anterior part traversing the interatrial septum
to supply the SA node, thus establishing a direct or indirect
anastomosis with the RCA, as mentioned by Kugel in 1927.[15] The
appearance of the left conus was not a constant feature; it was
seen in 3 out of 60 cases, originating either from LCA or LAD.
Variation in the origin of coronary arteries and their branching
pattern can pose difficulties in imaging by conventional catheters,
thereby creating problems in diagnostic and therapeutic
interventions.
In the present study, the overall prevalence of myocardial
bridging and looping was found to be 88% on cadaver dissection.
It was found to be more common in the left coronary system
(60%) than in the right coronary system (23.8%). In the left
coronary system, the myocardial bridging was frequently seen in
the LAD artery (43%). In the LAD artery, it was more commonly
found in the middle 1/3rd portion of the artery. A variation
was encountered by the occurrence of myocardial bridging
over the proximal and distal segments. This finding concurs
with the findings reported by Sabnis.[16] Along its course in the
right atrioventricular groove in 6.7% of the cases, RCA showed
myocardial looping, which is an anatomic variation.
The frequency of myocardial bridging in left anterior
interventricular was 23% according to Geringer[17] and 85.7%
according to Polaeck,[18] based on cadaveric dissection. The
myocardial bridges over the branches of RCA are rare as they
are found in 2.8 to 11.4% of cases. Muscular loops occur more
frequently in the course of circumflex as compared to that in
RCA. There is a paucity of references regarding myocardial loops
in the literature. The overall incidence of myocardial bridging
in LCA was found to be 77.1%, while it was found to be 41.4%
in RCA in a study by Poelack.[18] Kramer[19] in 1982 stated that
myocardial bridges that are present right from the period of
development are not the source of myocardial ischemia. The
frequency of detection of bridging in angiographic films is
0.5-12%.[20] It is seen as a systolic narrowing of arteries in a
coronary angiogram. The findings of myocardial bridging in
the present study concurs with that of Bandopadyay[21] et al., and
Vanildo,[22] who found it to be 90.40% and 86.6%, respectively.
However, it was 65.7% in a study by Sabnis[16] and 55.60% in
a study by Ferreira.[23] These values are less as compared to
that found in the present study. Myocardial bridge may cause
myocardial ischemia. It may require surgical repair and supra
arterial decompression myotomy. Localization and progression
of stenotic lesions of coronary arteries can be influenced by
anatomical characters of coronary arteries.[24] Study of myocardial
bridges requires further in-depth analyses.
50

CONCLUSION
Most of the variations are totally benign; some are errors
of embryological developmental timing or persistence of an
embryologic condition. Coronary artery variations are important
from clinical and surgical point of view. The study of coronary
artery variation is important to prevent false interpretation of the
coronary artery angiograms and to study and manage diseases
related to coronary arteries.

ACKNOWLEDGEMENT
Department of Anatomy, Seth GS Medical College, KEM Hospital,
Mumbai.

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How to cite this article: Kulkarni JP. Variant anatomy of coronary arteries. Heart India 2013;1:46-51.
Source of Support: Department of Anatomy, Seth GS Medical College,
KEM Hospital, Mumbai, Conflict of Interest: No conflict of interest.

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