Anomalous aortic origin of the right coronary artery (AAORCA) following an interarterial path can lead to myocardial ischemia and sudden cardiac death (SCD), necessitating surgical management in patients with symptoms. We present a case of a 35-year-old male experiencing exertional angina with reduced functional capacity. Computed tomography coronary angiography (CTCA) demonstrated the right coronary artery (RCA) arising from the left coronary cusp, characterized by a brief intramural segment, dangerous interarterial course, and elevated bifurcation creating dual RCA/posterior descending artery (PDA) branches. The intricate branching anatomy, combined with the abbreviated intramural portion, made unroofing an unfavorable option. We performed a right-sided minimally invasive direct coronary artery bypass (MIDCAB) employing a right internal mammary artery (RIMA)-radial artery composite graft to the PDA, accompanied by proximal native vessel ligation. Successful revascularization was achieved with graft patency confirmed on postoperative imaging, absence of myocardial infarction, and smooth recovery leading to discharge on postoperative day two. This experience suggests that composite arterial grafting through a minimally invasive technique provides effective symptom resolution in anatomically challenging AAORCA cases where conventional surgical approaches are not optimal.
Kurien et al. (2026) studied this question.