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(Circulation. 2006;114:e545-e546.)
© 2006 American Heart Association, Inc.

Images in Cardiovascular Medicine

Vieussens’ Ring

Combining Computed Tomography Coronary Angiography and Magnetic Resonance Imaging in Assessing Collateral Pathways

Mark W. Hansen, MBBS; Naeem Merchant, MD

From the Department of Medical Imaging, Toronto General Hospital, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada.

Correspondence to Dr Mark Hansen, Toronto General Hospital, 200 Elizabeth St, M5G 2C4, Toronto, Canada. E-mail markhansen74{at}mac.com

A 58-year-old man with a history of bicuspid aortic valve and severe childhood bacterial endocarditis presented to the Radiology Department for further investigation into the complex perivalvular anatomy seen on echocardiography and for assessment of the ascending aorta. Magnetic resonance imaging demonstrated a normal-caliber ascending aorta and a large perivalvular cavity. In addition, however, it showed dilated tortuous coronary arteries and an unusual appearance of the right coronary artery (RCA) origin (Figures 1 through 3). Phase-contrast imaging demonstrated retrograde flow within the mid RCA, presumably caused by large collaterals from the left coronary circulation.

View larger version (68K): [in this window] [in a new window]   Figure 1. Three-dimensional volume–rendered CT demonstrating Vieussens’ collateral pathway (labeled with a yellow asterisk on the volume-rendered image and outlined in yellow on the line diagram). A stenosis was identified at the RCA origin (open arrow) and at the origin of the right conus artery (black arrow). Note the large perivalvular space (+) adjacent to the RCA origin. This space communicates with the RCA.

View larger version (43K): [in this window] [in a new window]   Figure 2. Three-dimensional volume–rendered CT demonstrating the collateral pathway from the circumflex coronary artery to the right coronary artery (labeled yellow on the line diagram). 1, Circumflex to obtuse marginal branch; 2, obtuse marginal to acute marginal branch at the inferior aspect of the heart; 3, acute marginal branch to the right coronary artery; 4, right coronary artery.

View larger version (104K): [in this window] [in a new window]   Figure 3. Magnitude and velocity-encoded magnetic resonance images in the axial plane demonstrating retrograde flow encoded as "black" within the right coronary artery (*) and antegrade flow encoded as "white" within the circumflex coronary artery (+). Note the numerous prominent septal perforator branches visualized as white dots in the interventricular septum.

An ECG-gated computed tomography (CT) scan was performed to help further delineate the anatomy. This showed that the large perivalvular space communicated with the left ventricular outflow tract and aortic root through numerous fenestrations. The RCA origin was severely stenotic. Distally, the RCA was supplied by numerous collaterals from the left coronary circulation, as implied by magnetic resonance imaging.

One collateral pathway included a long, tortuous connection from the left circumflex coronary artery through an obtuse marginal branch traveling around the inferior aspect of the heart and communicating through an acute marginal branch with the RCA. The other major collateral pathway passed from the left anterior descending artery across the right ventricular outflow tract to the RCA through the right conus artery. This second collateral is also known by its eponymous name of Vieussens’ collateral pathway.^1,2 Also identified in this study is a significant stenosis of the right conus branch near its origin from the RCA, which affected its capacity to act as a collateral pathway.

It is postulated that the clinically documented episode of severe bacterial endocarditis in childhood probably resulted in a perivalvular abscess, leading to the formation of a perivalvular cavity and stenosis of the RCA origin. This in turn eventually led to the formation of these impressive collateral pathways.

	Disclosures

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None.

	References

Top Disclosures References

 
1. O’Leary EL, Garza L, Williams M, McCall D. Vieussens’ ring. Circulation. 1998; 98: 487–488.[Free Full Text]

2. Germing A, Mugge A. Images in cardiology: Vieussens’ ring. Clin Cardiol. 2003; 26: 441.[Medline] [Order article via Infotrieve]

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hansen, M. W. Articles by Merchant, N. Search for Related Content PubMed PubMed Citation Articles by Hansen, M. W. Articles by Merchant, N. Related Collections Cardiovascular imaging agents/Techniques Coronary imaging: angiography/ultrasound/Doppler/CC CT and MRI