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Aortic Root Sign

Knecht, Samuel M. BA; Jeudy, Jean MD; White, Charles S. MD

Journal of Thoracic Imaging: May 2018 - Volume 33 - Issue 3 - p W13
doi: 10.1097/RTI.0000000000000324
Web Exclusive Content-Signs in Cardiopulmonary Imaging

The authors declare no conflicts of interest.

Appearance: The aortic root sign describes an anomalous circumflex coronary artery (ACCA) that emerges from the contralateral coronary sinus, and travels underneath the aorta to supply blood to its normal vascular territory.

Explanation: The moniker, “aortic root sign,” was first coined by Page et al1 on conventional angiography to describe ACCA as arising from the proximal right coronary artery or right coronary sinus. The aberrant vessel courses inferiorly behind the aortic root within the groove between the left atrium and aorta,2 hence the term “aortic root sign” (Fig. 1).



Discussion: Traditionally coronary artery anomalies (CAAs) were thought to have little significance, and were often discovered as incidental findings on angiography. However, patients may present with clinically significant disease.2 In fact, CAAs are the second most common cause of sudden cardiac death in young athletes in the United States.2

ACCA was first described by Antopol and Kugel.3 The prevalence of ACCA reported in the coronary angiography literature ranges from 0.18% to 0.67%, making it the most common CAA. Some authors postulate that the oblique angulation of its origin predisposes ACCA to atherosclerosis. However, most clinicians agree that ACCA is a benign, asymptomatic anomaly. Indeed, the retroaortic course of ACCA, as described by the aortic root sign, rarely leads to ischemia or sudden cardiac death. On the contrary, CAAs that travel along an interarterial course between the aorta and pulmonary artery are more prone to ischemia during strenuous exercise.2

Despite the low risk of ischemia and sudden death with ACCA, recognition of this anomaly is still of great clinical importance because failure to identify this aberrant vessel can lead to adverse patient outcomes, especially during cardiac surgery. Therefore, it is crucial for the angiographer as well as the radiologist to be adept at recognizing ACCA and the other coronary anomalies, especially given the ease of diagnosis with noninvasive coronary imaging techniques, such as multidetector computed tomography4 and cardiac magnetic resonance imaging.5

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1. Page HL Jr, Engel HJ, Campbell WB, et al. Anomalous origin of the left circumflex coronary artery: recognition, angiographic demonstration and clinical significance. Circulation. 1974;50:768–773.
2. Patronis ME, Papaspyros SC, Shaikhrezai K, et al. Bypass grafting of aberrant circumflex artery with anomalous origin and course. Open Journal of Thoracic Surgery. 2012;2:121–125.
3. Antopol W, Kugel MA. Anomalous origin of the left circumflex coronary artery. American Heart Journal. 1933;8:802–806.
4. Tabari A, Lo Gullo R, Murugan V, et al. Recent advances in computed tomographic technology: cardiopulmonary imaging applications. J Thorac Imaging. 2017;32:89–100.
5. Cannaò PM, Muscogiuri G, Schoepf UJ, et al. Technical feasibility of a combined noncontrast magnetic resonance protocol for preoperative transcatheter aortic valve replacement evaluation. J Thorac Imaging. 2018;33:60–67.
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