Left main coronary artery compression associated with unfavorable thoracic anatomy

Article information

Korean J Intern Med. 2025;40(6):1065-1067

Publication date (electronic) : 2025 October 31

doi : https://doi.org/10.3904/kjim.2025.172

Daeung Ohn¹, Yeon-Jik Choi¹, Jin-Young Yoo², Suk-Min Seo¹, Junghoon Lee¹

¹Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

²Department of Radiology, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Correspondence to: Junghoon Lee, M.D. Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 1021 Tongil-ro, Eunpyeong-gu, Seoul 03312, Korea, Tel: +82-2-2030-4402, Fax: +82-2-2030-4641 E-mail: me@leejunghoon.com, https://orcid.org/0000-0003-0617-3116

Received 2025 June 1; Accepted 2025 June 3.

A 23-year-old male presented with exertional chest pain that began a month prior. He had undergone patent ductus arteriosus closure in the neonatal period and exhibited no significant findings on physical examination except for a shallow chest cavity.

Electrocardiography and echocardiography results were within normal limits. However, cardiac computed tomography angiography revealed significant left main coronary artery (LMCA) stenosis due to an acute angle and relatively high takeoff of the LMCA, coursing between the aorta and pulmonary trunk (Fig. 1, Supplementary Video 1). Subsequent coronary angiography confirmed significant LMCA stenosis, and intravascular ultrasound demonstrated gradual narrowing of the proximal vessel lumen compared to distal reference, suggesting extrinsic compression rather than plaque accumulation. (Fig. 2). Considering the patient’s overall clinical assessment and multimodal imaging findings, he underwent coronary artery bypass graft surgery and recovered uneventfully.

Figure 1

Cardiac computed tomography angiography of the left coronary artery. (A) An axial image of cardiac computed tomography angiography demonstrates severe stenosis at the ostium of the left main coronary artery, which exhibits a high take-off with an acute angle and an interarterial course. (B) Enlarged view of the origin of the left main coronary artery, corresponding to the boxed area in (A). (C, D) Three-dimensional volume-rendered and maximum intensity projection images illustrate a relatively high take-off with an acute angle of the left main coronary artery.

Figure 2

Coronary angiography and corresponding intravascular ultrasound (IVUS) images of the left coronary artery. (A, B) Coronary angiography revealed significant focal stenosis in the proximal left main artery, while the distal branches demonstrated preserved flow. (C) Coronary angiography with markers indicating the locations of IVUS cross-sectional images. (D, E) IVUS frames of the proximal left anterior descending artery and distal left main coronary artery show normal vessel anatomy without atherosclerosis. (F) IVUS frame of the proximal left main coronary artery demonstrates a luminal narrowing without significant plaque burden, likely due to external compression caused from anatomical deformity.

Coronary compression due to unfavorable anatomy has been associated with anomalous aortic origin of a coronary artery [1–3]. While uncommon, this condition can manifest as exertional chest pain in adolescence and can lead to coronary compromise, including sudden cardiac death [1–3]. Although this case does not fit within the category of congenital anomaly, it shares anatomical characteristics affecting the takeoff and course of the LMCA. Furthermore, LMCA compression, though extremely rare, is clinically significant. Therefore, in young patients with exertional chest pain, early imaging is crucial to distinguish extrinsic vascular compression from primary coronary artery disease and to guide appropriate management.

Informed consent was obtained from patients.