"Arterial circle of Vieussens" - An important intercoronary collateral.

A 66-year-old male smoker with past history of hypertension was admitted with chest pain of 8-hour duration. 12-lead electrocardiogram revealed complete heart block with inverted T waves in leads V1–6. Transthoracic echocardiography revealed fair left ventricular systolic function (LVEF ~ 50%). Serum biochemistry was normal except significantly raised troponin. After informed consent, coronary angiography via right transradial approach with 5F TIG catheter revealed significant stenotic lesion in mid left anterior descending (LAD) artery (Fig. 1A; S Video 1). While attempting for selective right coronary artery (RCA) cannulation, TIG catheter was engaged to separately originating conus artery which revealed collaterals providing flow to LAD distal to the stenotic lesion (arrow Fig. 1B; S Video 2). Right coronary artery (RCA) and left circumflex artery (LCX) were non-obstructive. Patient underwent successful percutaneous coronary intervention (PCI) to LAD with TIMI III flow and spontaneously reverted to sinus rhythm on the 3rd day post-PCI. Computed tomography (CT) coronary angiography delineated the course of conus artery which after an origin from the right coronary sinus passes anteriorly and superiorly to the right ventricle outflow tract towards LAD and giving collaterals to it (Fig. 2A, B). This pattern of collaterals to LAD from the conus artery is known as “arterial circle of Vieussens” (or ‘Vieussens’ ring). Patient was discharged in hemodynamically stable condition and was asymptomatic at 1-month follow-up.

Fig. 1

AP view of left coronary angiogram revealing significant stenotic lesion in mid LAD (panel A). AP view of separately arising conus artery giving collaterals (arrow) to mid LAD distal to the lesion (broken arrow, panel B). (AP, anteroposterior; LAD, left anterior descending artery).

Fig. 2

Reconstructed 3-D VRT image of CT coronary angiography revealing the course of conus artery which after origin courses superiorly and left (panel A) towards LAD anterior to RVOT (panel B). (VRT, volume rendering technique; CT, computed tomography; LAD, left anterior descending artery).

A 66-year-old male smoker with past history of hypertension was admitted with chest pain of 8-hour duration. 12-lead electrocardiogram revealed complete heart block with inverted T waves in leads V1–6. Transthoracic echocardiography revealed fair left ventricular systolic function (LVEF ~ 50%). Serum biochemistry was normal except significantly raised troponin. After informed consent, coronary angiography via right transradial approach with 5F TIG catheter revealed significant stenotic lesion in mid left anterior descending (LAD) artery (Fig. 1A; S Video 1). While attempting for selective right coronary artery (RCA) cannulation, TIG catheter was engaged to separately originating conus artery which revealed collaterals providing flow to LAD distal to the stenotic lesion (arrow Fig. 1B; S Video 2). Right coronary artery (RCA) and left circumflex artery (LCX) were non-obstructive. Patient underwent successful percutaneous coronary intervention (PCI) to LAD with TIMI III flow and spontaneously reverted to sinus rhythm on the 3rd day post-PCI. Computed tomography (CT) coronary angiography delineated the course of conus artery which after an origin from the right coronary sinus passes anteriorly and superiorly to the right ventricle outflow tract towards LAD and giving collaterals to it (Fig. 2A, B). This pattern of collaterals to LAD from the conus artery is known as “arterial circle of Vieussens” (or ‘Vieussens’ ring). Patient was discharged in hemodynamically stable condition and was asymptomatic at 1-month follow-up.

Coronary collateral circulation has an important role in the pathophysiology of coronary artery disease and is a predictor of symptoms and prognosis. Vieussens' ring is a crucial coronary collateral pathway providing flow between LAD and RCA in case of significant stenotic lesion in the either of the vessel. It is seen in 20% of the patients with total occlusion of LAD supplying its distal segment, [1]. The presence of significant collaterals to LAD should be suspected with significant flow limiting obstruction to LAD and fairly preserved LVEF, as in our case. It also has a therapeutic significance during surgery while manipulating right ventricle infundibulum and during PCI in LAD chronic total occlusion for visualizing distal LAD by simultaneous contrast injection.

We confirm that this report adheres to the stamens on ethical publishing as outlined in Shewan LG, Coats AJ. Int J Cardiol. 2012.

The following are the supplementary data related to this article.

S Video 1

Selective left coronary angiography revealing significant mid left anterior descending coronary artery stenosis.

S Video 2

Selective coronary angiography showing conus artery giving collateral to mid left anterior descending coronary artery distal to lesion.

Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.ijchv.2014.02.006.