An Unusual Angiographic Pattern of the Right Coronary Artery

BACKGROUND: Woven coronary artery (WCA) is a rare congenital anomaly in which a coronary artery divides into multiple fine intertwining channels that reanastomose distally. Although historically considered benign, emerging evidence suggests an association with thrombus formation, myocardial ischemia, and acute coronary syndromes. CASE SUMMARY: A 48-year-old man with a history of patent foramen ovale closure, rheumatoid arthritis, and tobacco use presented with several months of atypical chest pain and exertional fatigue. Coronary computed tomography angiography with fractional flow reserve demonstrated multivessel atherosclerotic disease with functionally significant stenoses. Invasive angiography revealed a woven pattern of the right coronary artery, characterized by dual luminal channels that rejoined mid-vessel and continued in a zigzag course with obstructive disease and also noted left anterior descending artery and left circumflex artery atherosclerotic disease. DISCUSSION: The diagnosis of WCA was based on its characteristic angiographic morphology, distinct from spontaneous coronary artery dissection, or recanalized thrombus. Coronary computed tomography angiography with fractional flow reserve confirmed physiologic significance and guided management. TAKE-HOME MESSAGE: This case underscores the importance of recognizing WCA as a potential contributor to ischemia and the value of combining anatomic and physiologic imaging for accurate diagnosis and optimal care.