Dual Conal Branch LAD Revascularization via Vieussens’ Ring on CCTA

Dual Conal Branch LAD Revascularization via Vieussens’ Ring on CCTA | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Dual Conal Branch LAD Revascularization via Vieussens’ Ring on CCTA Mario Finazzo, Manfredi Ballo, Francesca Finazzo, Cristiana Duranti This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8302369/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract We report a middle-aged woman with hypertension, dyslipidemia, and prior PCI with stents in the proximal LAD and a major diagonal who presented with exertional angina despite a negative stress ECG and underwent CCTA. CCTA demonstrated chronic total occlusion of the mid-LAD immediately distal to the proximal LAD stent, with distalperfusion entirely collateral-dependent. A conal branch from the right coronary ostium formed a Vieussens’ arterial ring and bifurcated: one branch entered the LAD at the junction between a normal-caliber segment and a subsequent long suboccluded tract, while the other revascularized the distal LAD. Additional collaterals arose from a large diagonalbranch. Both stents were patent. A severe ostial Left Circumflex artery stenosis was identified as the most likely culpritlesion. This case illustrates an uncommon dual conal-branch collateralization pattern and underscores the value of CCTA in complex CTO evaluation. Cardiac & Cardiovascular Systems Coronary CT angiography Vieussens’ arterial ring Conal branch Coronary collateral circulation Chronic total occlusion Figures Figure 1 Full Text Global Illumination images (A–C) show a chronic total occlusion of the mid LAD (long arrow) with two conal branches (c, short arrows) arising from the RCA ostium (r) and revascularizing separate LAD segments via the Vieussens’ arterial ring. The same reconstructions demonstrate a long suboccluded LAD segment (asterisk) and additional collateral supply from a large diagonal branch (curved arrow). Curved MPR image (C) confirms patency of the stents in the proximal LAD and in the major diagonal branch (double-headed arrow). An inverted MIP image (D) depicts a focal, severe ostial stenosis of the left circumflex artery (dashed arrows). Discussion A middle-aged woman with hypertension, dyslipidemia, and prior PCI with stents in the proximal Left Anterior Descending artery (LAD) and a major diagonal presented with exertional angina despite a negative stress ECG, prompting CCTA. CCTA demonstrated chronic total occlusion (CTO) of the mid-LAD immediately beyond the patent proximal LAD stent, with distal perfusion entirely collateral-dependent. Beyond the occlusion, the LAD showed a proximally well-opacified, normal-caliber segment followed by a long, markedly narrowed sub-occluded tract. A conal branch arising from the Right Coronary ostium formed a Vieussens’ arterial ring and bifurcated. The first branch entered the LAD precisely at the transition between the normal-caliber segment and the suboccluded tract. The second branch coursed further distally to revascularise the terminal LAD beyond the sub-occlusion. Additional collateral supply arose from a large diagonal branch. Both previously implanted stents were widely patent. CCTA also demonstrated a severe focal ostial stenosis of the Left Circumflex artery, regarded as the most likely cause of symptoms. The remaining coronary segments showed no significant disease. This case depicts an uncommon dual conal-branch collateralization pattern and underscores the value of CCTA in delineating complex collateral networks and guiding revascularization strategies [ 1 – 3 ]. Declarations The patient gave written permission for both participation and the publication of his clinical case. Funding declaration: No funding References Mantini C, Di Mascio V, Mastrodicasa D, Olivieri M, Procaccini L, Clemente A, Ricci F, Cademartiri F (2022) Vieussens’ ring coronary collateral circulation: a natural bypass history. Acta Biomed 93(S1):e2022111. 10.23750/abm.v93iS1.10865 Bhasin D, Shrimanth YS, Sharma YP, Panda P (2022) Vieussens' Arterial Ring. J Invasive Cardiol 34(4):E343–E344. 10.25270/jic/21.00390 Zia B, Ali S, Ali A, Samman A, Farooqui S, Khalid E, Khan S (2024) Circle of Vieussens: Its Importance in the Presence of Significant Coronary Artery Stenosis in a 26-Year-Old Female With Kawasaki Disease. Cureus 10(8):16. 10.7759/cureus.66601 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8302369","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":556624081,"identity":"941fc9d0-951d-41c6-ab7d-e607e2d624c6","order_by":0,"name":"Mario Finazzo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYJCCAww2EhDWx382QJKx8QBhLWkQLYwz2NJAVANBLQwMaRCKmYPtMNQQPEC3/ezDAx8SLPL4+48/fMzAc95ubfthoC01NtG4tJidSTc4OCNBoljiwIFk4wKJ28nbziQCtRxLy23ApeVAGsNh3h8SiQ0HG45JzzC4nWx2AKiFseEwbi3nnzEc5kmQSJx/mLFNmifhXLLZ+YcEtNxIg2jZcIyZTZrnwAE7sxuEbLnxjAHkl8SNZ9iYDWc2JCeY3QDakoDPL+fTmD98SKhLnHf++MMHHxvs7M3Opz988KHGBqcWDJAIVplArHIQsCdF8SgYBaNgFIwMAABi4Wi8Q1/gAQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-1518-5231","institution":"Studio di Radiologia Finazzo, Via Francesco Crispi 94, 90139, Palermo, Italy","correspondingAuthor":true,"prefix":"","firstName":"Mario","middleName":"","lastName":"Finazzo","suffix":""},{"id":556624224,"identity":"58d5c913-930e-4309-ac4c-9915eac91c22","order_by":1,"name":"Manfredi Ballo","email":"","orcid":"https://orcid.org/0009-0003-2067-6366","institution":"Angiomedica, Via Ruggero Settimo 55, 90139, Palermo, Italy","correspondingAuthor":false,"prefix":"","firstName":"Manfredi","middleName":"","lastName":"Ballo","suffix":""},{"id":556624453,"identity":"1f93ed9f-40d6-4b0a-a248-869e99b93599","order_by":2,"name":"Francesca Finazzo","email":"","orcid":"https://orcid.org/0009-0002-0257-7076","institution":"Studio di Radiologia Finazzo, Via Francesco Crispi 94, 90139, Palermo, Italy","correspondingAuthor":false,"prefix":"","firstName":"Francesca","middleName":"","lastName":"Finazzo","suffix":""},{"id":556624690,"identity":"25cacbc6-29fd-4807-b0b2-9ce317f1c545","order_by":3,"name":"Cristiana Duranti","email":"","orcid":"https://orcid.org/0009-0008-9107-6970","institution":"Breast Unit, Arnas Ospedali Civico Di Cristina, Piazza Nicola Leotta 4, 90127, Palermo, Italy","correspondingAuthor":false,"prefix":"","firstName":"Cristiana","middleName":"","lastName":"Duranti","suffix":""}],"badges":[],"createdAt":"2025-12-08 00:50:32","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8302369/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8302369/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97965620,"identity":"330def60-edbd-45cb-beb3-cc85477ec2ef","added_by":"auto","created_at":"2025-12-11 09:49:56","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1871407,"visible":true,"origin":"","legend":"","description":"","filename":"Dualconal.docx","url":"https://assets-eu.researchsquare.com/files/rs-8302369/v1/fd87ae765a4721a7918fa4f6.docx"},{"id":97965618,"identity":"9776346d-9d1d-4a0c-aba8-0945c5fe9dab","added_by":"auto","created_at":"2025-12-11 09:49:56","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs8302369.json","url":"https://assets-eu.researchsquare.com/files/rs-8302369/v1/08f5075c3774b752cb79f64d.json"},{"id":97965625,"identity":"5fe82df2-926c-4a00-83c6-310c9d5d2ee5","added_by":"auto","created_at":"2025-12-11 09:49:56","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14843,"visible":true,"origin":"","legend":"","description":"","filename":"rs83023690enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8302369/v1/1b223a84a43782ec7dd3faa1.xml"},{"id":97965630,"identity":"84debb72-bc64-4af9-b76e-e88a79c4b9eb","added_by":"auto","created_at":"2025-12-11 09:49:56","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1847114,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8302369/v1/e7c8c13f6dcba540654cf6e1.jpeg"},{"id":97965619,"identity":"a169584f-74a5-417e-83f0-44b421eed75d","added_by":"auto","created_at":"2025-12-11 09:49:56","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83888,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8302369/v1/c95ccc59a8026e44de47a8a7.png"},{"id":97965635,"identity":"f92c8b32-99cf-4064-ad76-51efc1f981c4","added_by":"auto","created_at":"2025-12-11 09:49:56","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14115,"visible":true,"origin":"","legend":"","description":"","filename":"rs83023690structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8302369/v1/29c1a8185889d105aa408587.xml"},{"id":98423072,"identity":"50eff6bd-11c6-4063-a2de-99a547f71292","added_by":"auto","created_at":"2025-12-17 16:31:48","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":17938,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8302369/v1/c1baae8e7e070704d1dd4ba9.html"},{"id":98424002,"identity":"2f796eb6-31e3-4fb7-9d8b-6d651d414843","added_by":"auto","created_at":"2025-12-17 16:32:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":543077,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8302369/v1/624de6494b112ab908fa43fc.png"},{"id":98444130,"identity":"14fa725b-baf4-4a5e-82a5-a1d5de3654b0","added_by":"auto","created_at":"2025-12-17 17:15:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":857224,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8302369/v1/71dc0c62-d85f-4842-8f86-435de5d934cf.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eDual Conal Branch LAD Revascularization via Vieussens’ Ring on CCTA\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Full Text","content":"\u003cp\u003eGlobal Illumination images (A–C) show a chronic total occlusion of the mid LAD (long arrow) with two conal branches (c, short arrows) arising from the RCA ostium (r) and revascularizing separate LAD segments via the Vieussens’ arterial ring. The same reconstructions demonstrate a long suboccluded LAD segment (asterisk) and additional collateral supply from a large diagonal branch (curved arrow).\u003c/p\u003e\n\u003cp\u003eCurved MPR image (C) confirms patency of the stents in the proximal LAD and in the major diagonal branch (double-headed arrow).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn inverted MIP image (D) depicts a focal, severe ostial stenosis of the left circumflex artery (dashed arrows).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA middle-aged woman with hypertension, dyslipidemia, and prior PCI with stents in the proximal Left Anterior Descending artery (LAD) and a major diagonal presented with exertional angina despite a negative stress ECG, prompting CCTA. CCTA demonstrated chronic total occlusion (CTO) of the mid-LAD immediately beyond the patent proximal LAD stent, with distal perfusion entirely collateral-dependent. Beyond the occlusion, the LAD showed a proximally well-opacified, normal-caliber segment followed by a long, markedly narrowed sub-occluded tract.\u003c/p\u003e\u003cp\u003eA conal branch arising from the Right Coronary ostium formed a Vieussens\u0026rsquo; arterial ring and bifurcated. The first branch entered the LAD precisely at the transition between the normal-caliber segment and the suboccluded tract. The second branch coursed further distally to revascularise the terminal LAD beyond the sub-occlusion. Additional collateral supply arose from a large diagonal branch. Both previously implanted stents were widely patent.\u003c/p\u003e\u003cp\u003eCCTA also demonstrated a severe focal ostial stenosis of the Left Circumflex artery, regarded as the most likely cause of symptoms. The remaining coronary segments showed no significant disease. This case depicts an uncommon dual conal-branch collateralization pattern and underscores the value of CCTA in delineating complex collateral networks and guiding revascularization strategies [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe patient gave written permission for both participation and the publication of his clinical case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding declaration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMantini C, Di Mascio V, Mastrodicasa D, Olivieri M, Procaccini L, Clemente A, Ricci F, Cademartiri F (2022) Vieussens\u0026rsquo; ring coronary collateral circulation: a natural bypass history. Acta Biomed 93(S1):e2022111. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.23750/abm.v93iS1.10865\u003c/span\u003e\u003cspan address=\"10.23750/abm.v93iS1.10865\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhasin D, Shrimanth YS, Sharma YP, Panda P (2022) Vieussens' Arterial Ring. J Invasive Cardiol 34(4):E343\u0026ndash;E344. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.25270/jic/21.00390\u003c/span\u003e\u003cspan address=\"10.25270/jic/21.00390\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZia B, Ali S, Ali A, Samman A, Farooqui S, Khalid E, Khan S (2024) Circle of Vieussens: Its Importance in the Presence of Significant Coronary Artery Stenosis in a 26-Year-Old Female With Kawasaki Disease. Cureus 10(8):16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.66601\u003c/span\u003e\u003cspan address=\"10.7759/cureus.66601\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Studio di Radiologia Finazzo ","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Coronary CT angiography, Vieussens’ arterial ring, Conal branch, Coronary collateral circulation, Chronic total occlusion","lastPublishedDoi":"10.21203/rs.3.rs-8302369/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8302369/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe report a middle-aged woman with hypertension, dyslipidemia, and prior PCI with stents in the proximal LAD and a major diagonal who presented with exertional angina despite a negative stress ECG and underwent CCTA. CCTA demonstrated chronic total occlusion of the mid-LAD immediately distal to the proximal LAD stent, with distalperfusion entirely collateral-dependent. A conal branch from the right coronary ostium formed a Vieussens’ arterial ring and bifurcated: one branch entered the LAD at the junction between a normal-caliber segment and a subsequent long suboccluded tract, while the other revascularized the distal LAD. Additional collaterals arose from a large diagonalbranch. Both stents were patent. A severe ostial Left Circumflex artery stenosis was identified as the most likely culpritlesion. This case illustrates an uncommon dual conal-branch collateralization pattern and underscores the value of CCTA in complex CTO evaluation.\u003c/p\u003e","manuscriptTitle":"Dual Conal Branch LAD Revascularization via Vieussens’ Ring on CCTA","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-11 09:49:44","doi":"10.21203/rs.3.rs-8302369/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b910fa4f-4486-4378-a1c1-17968ca4015f","owner":[],"postedDate":"December 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":59237018,"name":"Cardiac \u0026 Cardiovascular Systems"}],"tags":[],"updatedAt":"2025-12-11T09:49:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-11 09:49:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8302369","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8302369","identity":"rs-8302369","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}