High-Takeoff Anomalous Right Coronary Artery Arising From The Ascending Aorta: A Case Report

High-Takeoff Anomalous Right Coronary Artery Arising From The Ascending Aorta: A Case Report | 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 High-Takeoff Anomalous Right Coronary Artery Arising From The Ascending Aorta: A Case Report PRAVEEN JEYA ARUL RAJ, AARTHY SUNDARAMURTHY, HARIKRISHNAN PARTHASARATHY This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8580379/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Apr, 2026 Read the published version in BMC Cardiovascular Disorders → Version 1 posted 20 You are reading this latest preprint version Abstract Background Anomalous origin of the coronary arteries is an uncommon congenital abnormality that may pose diagnostic challenges during invasive coronary angiography. High-takeoff origin of the right coronary artery (RCA) from the ascending aorta is particularly rare and can mimic ostial occlusion, potentially leading to prolonged procedures and inappropriate catheter manipulation. Computed tomography coronary angiography (CTCA) plays a crucial role in accurately defining the anatomical origin and course of anomalous coronary arteries and in guiding management. Case presentation A 70-year-old woman with diabetes mellitus, hypertension, hypothyroidism, and known mitral valve prolapse presented with intermittent palpitations. Electrocardiography revealed frequent ventricular premature complexes, and 24-hour Holter monitoring documented 9,259 premature ventricular complexes. Transthoracic echocardiography showed preserved biventricular systolic function with mild-to-moderate mitral regurgitation. Coronary angiography performed via the right radial artery demonstrated normal left coronary arteries but difficulty in engaging the RCA in its expected location. After systematic angiographic exploration using alternative catheter strategies, the RCA was selectively engaged from a slit-like ostium located above the left coronary cusp. CT coronary angiography confirmed anomalous origin of the RCA from the anterior and left lateral wall of the ascending aorta, 20.9 mm above the sino-tubular junction, with a short interarterial course measuring 1.9 cm and no luminal narrowing or compression. The patient was managed conservatively and remained clinically stable. Conclusions High-takeoff anomalous origin of the RCA from the ascending aorta is a rare but important diagnostic consideration when selective coronary engagement is challenging. Early recognition and use of CT coronary angiography are essential for accurate diagnosis and risk stratification. Anomalous coronary artery Right coronary artery High-takeoff coronary artery Coronary angiography CT coronary angiography Interarterial course Figures Figure 1 Figure 2 Figure 3 Background Coronary artery anomalies are detected in approximately 0.3–1% of patients undergoing coronary angiography or cardiac computed tomography [ 1 , 2 ]. Among these, anomalous origin of the right coronary artery (RCA) accounts for nearly 0.1% of cases [ 2 ]. High-takeoff RCA arising from the ascending aorta above the sino-tubular junction is exceedingly rare and has been described predominantly in isolated case reports.[ 3 ] Although many coronary anomalies are clinically benign, failure to recognize aberrant origins during invasive coronary angiography may result in diagnostic confusion, prolonged procedural time, and unnecessary catheter manipulation. CT coronary angiography provides definitive anatomical characterization and plays a key role in risk stratification and management planning [ 4 – 6 ]. Case presentation A 70-year-old woman presented with intermittent palpitations of several months’ duration. She denied chest pain, exertional dyspnea, syncope, or presyncope. Her medical history included diabetes mellitus, hypertension, hypothyroidism, and mitral valve prolapse. She was receiving beta-blocker therapy and amiodarone for symptomatic ventricular ectopy. Electrocardiography demonstrated sinus rhythm with frequent ventricular premature complexes. Twenty-four-hour Holter monitoring recorded 9,259 premature ventricular complexes without sustained arrhythmia. Transthoracic echocardiography showed prolapse of the A2–A3 scallops of the mitral valve with mild-to-moderate eccentric mitral regurgitation and mild left atrial enlargement. Left and right ventricular systolic functions were preserved, left ventricular filling pressures were normal, and there were no regional wall motion abnormalities. Coronary angiography was performed via the right radial artery using a 5-French sheath. The left coronary system was engaged easily with a TIG catheter and demonstrated normal epicardial coronary arteries. Multiple attempts to engage the RCA in the right coronary sinus were unsuccessful (Fig. 1 ). A Judkins Right catheter was subsequently used, and systematic exploration of both coronary sinuses failed to identify the RCA ostium. Careful probing of the ascending aorta using small-volume contrast injections eventually revealed a slit-like ostium located above the left coronary cusp, approximately 20 mm above the sino-tubular junction (Fig. 2 ). Angiography demonstrated a normal-caliber RCA without stenosis and a co-dominant coronary circulation. Discussion Coronary artery anomalies are identified in 0.3–1% of angiographic and CT-based studies, with anomalous RCA origin reported in approximately 0.1% of cases [ 1 , 2 ]. High-takeoff RCA from the ascending aorta represents a particularly rare variant [ 3 ]. Clinical relevance depends primarily on the proximal course rather than the site of origin alone. An interarterial course has historically been considered a malignant feature due to its association with ischemia and sudden cardiac death. However, contemporary consensus emphasizes a risk continuum influenced by ostial morphology, intramural segments, acute angulation, and dynamic compression [ 4 ]. In the present case, CT coronary angiography demonstrated a short interarterial segment without narrowing or compression, consistent with a benign anatomical variant. This case highlights an important diagnostic pitfall during coronary angiography. Failure to engage the RCA should prompt consideration of anomalous origin rather than immediate assumption of ostial occlusion. Systematic angiographic exploration and appropriate catheter selection are essential, particularly in emergency settings such as primary percutaneous coronary intervention, where delayed recognition may prolong reperfusion time. CT coronary angiography remains the gold standard for defining anomalous coronary anatomy and guiding management decisions [ 5 , 6 ]. Conclusion High-takeoff anomalous origin of the right coronary artery from the ascending aorta is a rare anatomical variant that may present a diagnostic challenge during coronary angiography. Awareness of this entity and early use of CT coronary angiography are crucial for accurate diagnosis, risk stratification, and appropriate management. Abbreviations RCA Right coronary artery CTCA Computed tomography coronary angiography ECG Electrocardiogram Declarations Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent was obtained from the patient for publication of this case report and accompanying images. Competing interests The authors declare that they have no competing interests. Authors’ information Not applicable. Funding The authors received no external funding for this work. Author Contribution PJAR conceived the case report, acquired clinical and angiographic data, and drafted the manuscript.HP performed the coronary angiogram, interpreted clinical and angiographic data and was a major contributor in writing the manuscript and also provided critical revision and final approval to the final manuscriptAS interpreted the CT coronary angiography images and critically revised the manuscript.All authors read and approved the final manuscript. Acknowledgements Not applicable. Data Availability All data generated or analysed during this study are included in this published article. References Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. 1990;21:28–40. 10.1002/ccd.1810210110 . Angelini P. Coronary artery anomalies: an entity in search of an identity. Circulation. 2007;115:1296–305. 10.1161/CIRCULATIONAHA.106.618082 . Cheezum MK, et al. Anomalous aortic origin of a coronary artery from the opposite sinus. JACC Cardiovasc Imaging. 2017;10:453–62. 10.1016/j.jacc.2017.01.031 . Taylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol. 1992;20:640–7. 10.1016/0735-1097(92)90019-j . Bigler MR, et al. Therapeutic management of anomalous coronary arteries. J Am Heart Assoc. 2022;11:e027098. 10.1161/JAHA.122.027098 . Ben-Dor I, et al. Catheter selection and angiographic views for anomalous coronary arteries. JACC Cardiovasc Interv. 2021;14:995–1008. 10.1016/j.jcin.2021.01.054 . Brothers JA, et al. Expert consensus guidelines: anomalous aortic origin of a coronary artery. J Thorac Cardiovasc Surg. 2017;153:1440–57. 10.1016/j.jtcvs.2016.06.066 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 29 Apr, 2026 Read the published version in BMC Cardiovascular Disorders → Version 1 posted Editorial decision: Revision requested 09 Feb, 2026 Reviews received at journal 06 Feb, 2026 Reviews received at journal 01 Feb, 2026 Reviews received at journal 31 Jan, 2026 Reviewers agreed at journal 27 Jan, 2026 Reviews received at journal 27 Jan, 2026 Reviewers agreed at journal 27 Jan, 2026 Reviews received at journal 26 Jan, 2026 Reviews received at journal 25 Jan, 2026 Reviewers agreed at journal 25 Jan, 2026 Reviewers agreed at journal 25 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers invited by journal 22 Jan, 2026 Editor invited by journal 14 Jan, 2026 Editor assigned by journal 13 Jan, 2026 Submission checks completed at journal 13 Jan, 2026 First submitted to journal 12 Jan, 2026 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. 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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-8580379","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":580316887,"identity":"5196a910-d734-45eb-8259-3ea74e42362a","order_by":0,"name":"PRAVEEN JEYA ARUL RAJ","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYBACxgZk3gcgZmMnXgszA+MMkBZm4i1kZmDmgdAE1M3uffiZp8Imj392/8HHNr+2yfMBbfvwMQePw+YcN5bmOZNWLHHnMLNxbt9twzagbZIzt+HRMiONQXJm2+HEhhvJbNK5PbcZgVrYmHnxa2H+OfPf/8T5IC2WPbftidHCJvGx4UDiBpAWhh+3EwlrmXOMzeLDseTEjTeSjQ17G24ntzEzNuP1i+HsNuYbCTV2ifNuJD588OPPbdv57c0HP3zEp2UGip1tYLIBt3ogkJdA4f7Bq3gUjIJRMApGKAAAigpQu2ETZJwAAAAASUVORK5CYII=","orcid":"","institution":"Apollo Speciality Hospitals, Vanagaram","correspondingAuthor":true,"prefix":"","firstName":"PRAVEEN","middleName":"JEYA ARUL","lastName":"RAJ","suffix":""},{"id":580316890,"identity":"bba7d90e-ddf7-4cde-bbb6-9f5a8a604eac","order_by":1,"name":"AARTHY SUNDARAMURTHY","email":"","orcid":"","institution":"Apollo Speciality Hospitals, Vanagaram","correspondingAuthor":false,"prefix":"","firstName":"AARTHY","middleName":"","lastName":"SUNDARAMURTHY","suffix":""},{"id":580316892,"identity":"15763fc0-8a2b-4578-bd32-274d34a0b42c","order_by":2,"name":"HARIKRISHNAN PARTHASARATHY","email":"","orcid":"","institution":"Apollo Speciality Hospitals, Vanagaram","correspondingAuthor":false,"prefix":"","firstName":"HARIKRISHNAN","middleName":"","lastName":"PARTHASARATHY","suffix":""}],"badges":[],"createdAt":"2026-01-12 10:23:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8580379/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8580379/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12872-026-05695-y","type":"published","date":"2026-04-29T15:57:32+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101274481,"identity":"27e2d02c-30d1-489c-8fd5-0c6f4189956d","added_by":"auto","created_at":"2026-01-28 03:10:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":167060,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCoronary angiography demonstrating anomalous right coronary artery origin.\u003c/strong\u003e Selective coronary angiography performed via the right radial approach showing difficulty in engaging the right coronary artery in its expected position, with subsequent visualization of the vessel arising from a high takeoff location above the left coronary cusp.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8580379/v1/5f4069966fd9c299965eb5d7.png"},{"id":101274448,"identity":"6b4d7210-681f-4467-9222-226b8b7f358f","added_by":"auto","created_at":"2026-01-28 03:10:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":171983,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHigh-takeoff origin of the right coronary artery on angiography.\u003c/strong\u003e \u003cbr\u003e\nCoronary angiographic image illustrating the slit-like ostium of the right coronary artery arising from the ascending aorta, approximately 20 mm above the sino-tubular junction (dashed lines), consistent with a high-takeoff anomalous origin.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8580379/v1/ed54601702c9625189c549ae.png"},{"id":101274389,"identity":"ba0ceba0-adc6-470b-be2a-7af7e0e0b8d1","added_by":"auto","created_at":"2026-01-28 03:10:17","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":104865,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComputed tomography coronary angiography confirming anomalous origin and course.\u003cbr\u003e\n \u003c/strong\u003eThree-dimensional volume-rendered computed tomography coronary angiography demonstrating anomalous origin of the right coronary artery from the anterior and left lateral wall of the ascending aorta with a short interarterial course between the ascending aorta and the main pulmonary artery.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8580379/v1/9981fd6bccdfbdb17b5937f8.png"},{"id":108437637,"identity":"e37f3f34-dad7-4d70-bc47-96b377a0b1a2","added_by":"auto","created_at":"2026-05-04 16:01:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":586891,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8580379/v1/4237b527-6dac-4aa1-bb95-76b31cd3d71f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"High-Takeoff Anomalous Right Coronary Artery Arising From The Ascending Aorta: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eCoronary artery anomalies are detected in approximately 0.3\u0026ndash;1% of patients undergoing coronary angiography or cardiac computed tomography [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Among these, anomalous origin of the right coronary artery (RCA) accounts for nearly 0.1% of cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. High-takeoff RCA arising from the ascending aorta above the sino-tubular junction is exceedingly rare and has been described predominantly in isolated case reports.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Although many coronary anomalies are clinically benign, failure to recognize aberrant origins during invasive coronary angiography may result in diagnostic confusion, prolonged procedural time, and unnecessary catheter manipulation. CT coronary angiography provides definitive anatomical characterization and plays a key role in risk stratification and management planning [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 70-year-old woman presented with intermittent palpitations of several months\u0026rsquo; duration. She denied chest pain, exertional dyspnea, syncope, or presyncope. Her medical history included diabetes mellitus, hypertension, hypothyroidism, and mitral valve prolapse. She was receiving beta-blocker therapy and amiodarone for symptomatic ventricular ectopy.\u003c/p\u003e \u003cp\u003eElectrocardiography demonstrated sinus rhythm with frequent ventricular premature complexes. Twenty-four-hour Holter monitoring recorded 9,259 premature ventricular complexes without sustained arrhythmia. Transthoracic echocardiography showed prolapse of the A2\u0026ndash;A3 scallops of the mitral valve with mild-to-moderate eccentric mitral regurgitation and mild left atrial enlargement. Left and right ventricular systolic functions were preserved, left ventricular filling pressures were normal, and there were no regional wall motion abnormalities.\u003c/p\u003e \u003cp\u003eCoronary angiography was performed via the right radial artery using a 5-French sheath. The left coronary system was engaged easily with a TIG catheter and demonstrated normal epicardial coronary arteries. Multiple attempts to engage the RCA in the right coronary sinus were unsuccessful (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A Judkins Right catheter was subsequently used, and systematic exploration of both coronary sinuses failed to identify the RCA ostium. Careful probing of the ascending aorta using small-volume contrast injections eventually revealed a slit-like ostium located above the left coronary cusp, approximately 20 mm above the sino-tubular junction (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Angiography demonstrated a normal-caliber RCA without stenosis and a co-dominant coronary circulation.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eCoronary artery anomalies are identified in 0.3\u0026ndash;1% of angiographic and CT-based studies, with anomalous RCA origin reported in approximately 0.1% of cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. High-takeoff RCA from the ascending aorta represents a particularly rare variant [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Clinical relevance depends primarily on the proximal course rather than the site of origin alone.\u003c/p\u003e \u003cp\u003eAn interarterial course has historically been considered a malignant feature due to its association with ischemia and sudden cardiac death. However, contemporary consensus emphasizes a risk continuum influenced by ostial morphology, intramural segments, acute angulation, and dynamic compression [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In the present case, CT coronary angiography demonstrated a short interarterial segment without narrowing or compression, consistent with a benign anatomical variant.\u003c/p\u003e \u003cp\u003eThis case highlights an important diagnostic pitfall during coronary angiography. Failure to engage the RCA should prompt consideration of anomalous origin rather than immediate assumption of ostial occlusion. Systematic angiographic exploration and appropriate catheter selection are essential, particularly in emergency settings such as primary percutaneous coronary intervention, where delayed recognition may prolong reperfusion time. CT coronary angiography remains the gold standard for defining anomalous coronary anatomy and guiding management decisions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHigh-takeoff anomalous origin of the right coronary artery from the ascending aorta is a rare anatomical variant that may present a diagnostic challenge during coronary angiography. Awareness of this entity and early use of CT coronary angiography are crucial for accurate diagnosis, risk stratification, and appropriate management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRight coronary artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography coronary angiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eECG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eElectrocardiogram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e Written informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors received no external funding for this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003ePJAR conceived the case report, acquired clinical and angiographic data, and drafted the manuscript.HP performed the coronary angiogram, interpreted clinical and angiographic data and was a major contributor in writing the manuscript and also provided critical revision and final approval to the final manuscriptAS interpreted the CT coronary angiography images and critically revised the manuscript.All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. 1990;21:28\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ccd.1810210110\u003c/span\u003e\u003cspan address=\"10.1002/ccd.1810210110\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAngelini P. Coronary artery anomalies: an entity in search of an identity. Circulation. 2007;115:1296\u0026ndash;305. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/CIRCULATIONAHA.106.618082\u003c/span\u003e\u003cspan address=\"10.1161/CIRCULATIONAHA.106.618082\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheezum MK, et al. Anomalous aortic origin of a coronary artery from the opposite sinus. JACC Cardiovasc Imaging. 2017;10:453\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jacc.2017.01.031\u003c/span\u003e\u003cspan address=\"10.1016/j.jacc.2017.01.031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol. 1992;20:640\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/0735-1097(92)90019-j\u003c/span\u003e\u003cspan address=\"10.1016/0735-1097(92)90019-j\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBigler MR, et al. Therapeutic management of anomalous coronary arteries. J Am Heart Assoc. 2022;11:e027098. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/JAHA.122.027098\u003c/span\u003e\u003cspan address=\"10.1161/JAHA.122.027098\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBen-Dor I, et al. Catheter selection and angiographic views for anomalous coronary arteries. JACC Cardiovasc Interv. 2021;14:995\u0026ndash;1008. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jcin.2021.01.054\u003c/span\u003e\u003cspan address=\"10.1016/j.jcin.2021.01.054\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrothers JA, et al. Expert consensus guidelines: anomalous aortic origin of a coronary artery. J Thorac Cardiovasc Surg. 2017;153:1440\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jtcvs.2016.06.066\u003c/span\u003e\u003cspan address=\"10.1016/j.jtcvs.2016.06.066\" 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":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Anomalous coronary artery, Right coronary artery, High-takeoff coronary artery, Coronary angiography, CT coronary angiography, Interarterial course","lastPublishedDoi":"10.21203/rs.3.rs-8580379/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8580379/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAnomalous origin of the coronary arteries is an uncommon congenital abnormality that may pose diagnostic challenges during invasive coronary angiography. High-takeoff origin of the right coronary artery (RCA) from the ascending aorta is particularly rare and can mimic ostial occlusion, potentially leading to prolonged procedures and inappropriate catheter manipulation. Computed tomography coronary angiography (CTCA) plays a crucial role in accurately defining the anatomical origin and course of anomalous coronary arteries and in guiding management.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 70-year-old woman with diabetes mellitus, hypertension, hypothyroidism, and known mitral valve prolapse presented with intermittent palpitations. Electrocardiography revealed frequent ventricular premature complexes, and 24-hour Holter monitoring documented 9,259 premature ventricular complexes. Transthoracic echocardiography showed preserved biventricular systolic function with mild-to-moderate mitral regurgitation. Coronary angiography performed via the right radial artery demonstrated normal left coronary arteries but difficulty in engaging the RCA in its expected location. After systematic angiographic exploration using alternative catheter strategies, the RCA was selectively engaged from a slit-like ostium located above the left coronary cusp. CT coronary angiography confirmed anomalous origin of the RCA from the anterior and left lateral wall of the ascending aorta, 20.9 mm above the sino-tubular junction, with a short interarterial course measuring 1.9 cm and no luminal narrowing or compression. The patient was managed conservatively and remained clinically stable.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eHigh-takeoff anomalous origin of the RCA from the ascending aorta is a rare but important diagnostic consideration when selective coronary engagement is challenging. Early recognition and use of CT coronary angiography are essential for accurate diagnosis and risk stratification.\u003c/p\u003e","manuscriptTitle":"High-Takeoff Anomalous Right Coronary Artery Arising From The Ascending Aorta: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 03:08:29","doi":"10.21203/rs.3.rs-8580379/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-09T11:12:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-06T05:29:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-02T02:49:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-31T14:30:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244772698281364598601388225191489145076","date":"2026-01-27T16:12:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T06:28:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8527053291325872315603878097124090879","date":"2026-01-27T06:18:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-26T06:24:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-25T12:58:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295970380646096130373534150756466830036","date":"2026-01-25T11:59:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243185846976213825895722184043970978687","date":"2026-01-25T07:38:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250287909559709058136151739945762852623","date":"2026-01-23T07:39:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80667044804195693951084081883218713108","date":"2026-01-23T04:02:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64796335406299959572836764391740363033","date":"2026-01-23T03:29:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173626587072725860161478336263302367196","date":"2026-01-22T17:21:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-22T13:48:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-14T09:52:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T06:36:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-13T06:33:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2026-01-12T10:01:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5198c604-fdfa-49ed-b2c1-485203a2019d","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:00:10+00:00","versionOfRecord":{"articleIdentity":"rs-8580379","link":"https://doi.org/10.1186/s12872-026-05695-y","journal":{"identity":"bmc-cardiovascular-disorders","isVorOnly":false,"title":"BMC Cardiovascular Disorders"},"publishedOn":"2026-04-29 15:57:32","publishedOnDateReadable":"April 29th, 2026"},"versionCreatedAt":"2026-01-28 03:08:29","video":"","vorDoi":"10.1186/s12872-026-05695-y","vorDoiUrl":"https://doi.org/10.1186/s12872-026-05695-y","workflowStages":[]},"version":"v1","identity":"rs-8580379","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8580379","identity":"rs-8580379","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}