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\title{May Preoperative Coronary Angiography Images Suggest About the
Intramyocardial Course of Left Anterior Descending Coronary Artery?}



\author[1]{Ferit Çiçekçioğlu}%
\author[2]{Kıvanc ATILGAN}%
\author[1]{Zafer Er}%
\author[3]{Ertan Demirdas}%
\affil[1]{Bozok University}%
\affil[2]{TOBB ETU Hospital}%
\affil[3]{University of Health Sciences Gulhane School of Nursing}%


\vspace{-1em}



  
  \date{April 25, 2026}


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\selectlanguage{english}
\begin{abstract}
Objective: The aim of this study is to define the correlation between
intramyocardial left anterior descending artery (IMLAD) and coronary
artery angiography (CAG); our clinical intraoperative experiences.
Material and Methods: Between January 2014 and May 2019, 196 patients
underwent coronary artery bypass grafting (CABG) surgery in Bozok
University Medicine Faculty Hospital. The correlation between the
typical ``wide-U'' image of left anterior descending artery (LAD)
depression(Cicekcioglu sign) on CAG and our intraoperative surgical
observations of the patients were studied. Results: Of the 196 patients,
5 were excluded due to the total occlusion of proximal LAD. 30 had a
typical ``wide-U'' image(Cicekcioglu sign) on CAG and 22 were observed
to have an IMLAD. Of the 25 patients being observed to have IMLAD
intraoperatively, 3 had a normal preoperative CAG imaging. The
prevalence of the IMLAD was 13\%. Sensitivity of CAG was measured as
88\% and specificity of CAG was 95.1\%. Discussion: In CAG, in case of
LAD composing a ``wide-U'' imaging(Cicekcioglu sign) the image of LAD
course is often observed to have a correlation with the intraoperative
detection of IMLAD.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Main coronary arteries show a behavior of proceeding subepicardial on
the surface of the heart and get into the myocardium almost at the
termination part.{[}1,2{]} However, in some cases it may become possible
to observe the coronary arteries proceeding intramyocardially even in
proximal and mid parts or all the course.{[}3,4{]}

Intramyocardial coronary arteries have always been a challenging
situation for the cardiac surgeons during coronary artery bypass
grafting (CABG) surgery due to the difficulties of targeting distal
anastomosis area leading to inadequate coronary revascularization and
intraoperative complications such as extended bypass time, a prolonged
ischemic interval, ventricular and coronary arterial injuries resulting
with intraoperative bleeding. {[}1,5-7{]}

Coronary artery angiography (CAG) is the gold-standard diagnosing
technique for coronary artery diseases (CAD). {[}1,3-5{]} Sometimes
typical images of the coronary arteries would suggest a typical anatomic
variation. Thus, a ``wide-U'' image of left anterior descending artery
(LAD) especially in right anterior oblique position would refer an
intramyocardial location.

In this research, we aimed to define the correlation between the typical
image of LAD in CAG and intraoperative observation of LAD course. In the
literature, there are many samples of researches made on intramyocardial
course of LAD and possible complications following surgery. However, our
research is the first to study the sensitivity and specificity of CAG.

\textbf{Material and Methods}

Study design and patient population: This retrospective cohort research
was studied in Bozok University Medicine Faculty Hospital Cardiovascular
Surgery Department and approved by the Ethics Committee of Bozok
University Medicine Faculty Hospital (Yozgat,
Turkey)(2017-KAEK-189\_2020.01.08\_17). This study complies with the
standards defined by the Declaration of Helsinki. Between January 2014
and May 2019, 196 patients had undergone CABG in Bozok University
Medicine Faculty Hospital. Of the 196 patients, five were excluded from
the study due to the total occlusion of proximal LAD. All the cases were
reported by the single surgeon who had done the CABGs. The
intramyocardial LAD (IMLAD) was identified by not being visualized on
the surface of the heart in any part of its entire course. Each CAG
images and reports of the patients contributing the study were analyzed
prospectively by consulting with Cardiology Department.

The main limitation of our research is the inadequate numbers of cases
in terms of statistical analysis. Therefore, the patient enrollment
process continues and a yearly report of results and statistics is
planned at the end of each 12 months.

\textbf{Statistical Analysis}

All data were entered in SPSS software (Statistical Package for Social
Sciences for Windows, version 16.0, Chicago, IL, USA) and analyzed.
Continuous variables were expressed as Mean\selectlanguage{ngerman}±SD or medians
(25\textsuperscript{th} and 75th percentiles) according to their
distributions and qualitative data were presented as numbers or
percentages. The prevalence, sensitivity and specificity of CAG were
calculated.

\textbf{Results}

Of the 191 patients, 106 (55.4\%) were male and 75 (44.6\%) were female
and the average age was 66±5.8 (Table 1). Of the 30 patients having
IMLAD image on CAG, 8 were observed to have an epicardial LAD and 22 had
an intramyocardial course. Of the 25 patients being observed to have
IMLAD intraoperatively, 3 had a normal preoperative CAG imaging. (Figure
1) In CAG group, of the 30 patients, 20 (66.7\%) were male and 10
(33.3\%) were female and average age was 64±6.2. In CABG group, of the
25 patients, 15 (60\%) were male and 10 (40\%) were female, and the
average age was 63±4.9.

The prevalence of the intramyocardial LAD in patients undergoing CABG
was 13\%. Sensitivity of CAG was measured as 88\% and specificity of CAG
was 95.1\%.

Of the 25 IMLAD cases, 20 (80\%) had a superficial course and five
(20\%) had a deeper course through the interventricular septum. In 20
cases, including the two deeply located IMLAD, LAD was grafted distally
where it became visible. In five cases, LAD was not visible even in
distal part. Great cardiac vein was used as a leading mark in order to
visualize IMLAD and LAD was grafted within the myocardium. No
intra/postoperative complication was observed in any of the IMLAD cases.

\textbf{Discussion}

Intramyocardial course of a coronary artery is an inborn anomaly and
defined as the intramural location of the artery through the myocardium.
{[}8,9{]} According to pathological serious the prevalence of
intramyocardial course ranges from 5\% to 86\% {[}10,11{]} and from
0.5\% to 33\% in angiographic series {[}13-14{]}. E A Vanker et al,
observed IMLAD in 293 patients undergoing CABG out of 1349 and reported
the prevalence of IMLAD as 21.7\%. {[}1{]} In our study, the prevalence
of the IMLAD in patients undergoing CABG was 13\%.

Thanks to the advantages of revealing the properties of coronary artery
obstructive lesions, conventional CAG remains the gold standard imaging
procedure for the diagnoses of coronary artery diseases.{[}15,16{]} In
some of the CAG procedures, LAD is seen diving into the myocardium at an
acute angle and coming back to the epicardial layer following a variable
length of course composing a ``wide-U'' imaging(Cicekcioglu sign), which
is seen more clearly on the right anterior oblique position. This LAD
depression sign was observed to have a correlation with the
intraoperative detection of IMLAD.

In case of an IMLAD as a target artery to be bypassed, there may be
compelling situations for the surgeon in terms of distal anastomosing
process. There are several options for locating IMLAD during surgery.
One is ``Blind dissection'' which is applied by dissecting myocardium in
the epicardial region of the anterior interventricular groove. This
technique may cause a severe damage to the subepicardial myocardium
resulting with the perforation of the ventricles. {[}17-19{]} Another
solution is using the great cardiac vein, which usually has a course in
the epicardial fat and stays more superficially than the artery, as a
leading point. Using a coronary probe, which is inserted to the artery
from the distal visible part, is another technique. However, the risk of
perforating the coronary artery may cause serious intraoperative
morbidities. {[}20{]} Performing doppler ultrasound with a color doppler
microprobe, intraoperative fluorescence angiography and cineangiography
are other less invasive but respectively more expensive techniques for
locating IMLAD. {[}21-24{]}

\textbf{Conclusion:}

The anterior cardiac wall infarction is usually a result of the
atherosclerosis of LAD, which has the highest ratio of intramuscular
course in comparison to remaining coronary arteries. LAD is the most
common affected coronary artery,and mostly the left internal mammary
artery (LIMA) is preferred to graft it. In case of predicting and
locating IMLAD preoperatively, it would be able to avoid many
intraoperative management complications. Therefore, we planned to
investigate whether CAG could be used as a predictive test for IMLAD,
and a sensitivity score of 88 \% was encouraging in terms of predicting
IMLAD before surgery.

\textbf{References}

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16 Ellis S, Alderman E, Cain K, Fisher L, Sanders W, Bourassa M.
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coronary arteries. Ann Thorac Surg 1984;38:356--362.

19 Parachuri R, Chattuparambil B: Marsupialization of intramyocardial
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20 Apostolakis E, Koletsis E, Leivaditis V, et al: A safe technique of
exposing of a `hidden' left anterior descending artery. J Card Surg
2007;22:505--506.

21 Ziadinov E, Al-sabti H: Localizing intramyocardially embedded left
anterior descending artery during coronary bypass surgery: Literature
review. J Cardiothorac Surg

2013;1--5.

22 Miwa S, Nishina T, Ueyama K, et al: Visualization of intramuscular
left anterior descending coronary arteries during off-pump bypass
surgery. Ann Thorac Surg 2004;

77:344--346.

23 Singh SK, Ihnken KA: Intraoperative fluorescence angiography to
identify and confirm repair of intramyocardial left anterior descending
coronary artery aneurysm. Ann Thorac Surg 2010;90:e62.

24 Aydin U, Kocogullari CU: A method for locating embedded left
anterior. Ann Thorac Surg 2013;95:360--361.

Figure 1. LAD depression and ``wide-U'' (Cicekcioglu sign) (arrow) {[}a.
Right caudal b. Right cranial oblique c. Right cranial oblique d.
Anterior-posterior cranial{]}

Table 1. Demographic data of the participants\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& All Patients & CAG Group & CABG Group & P\tabularnewline
\midrule
\endhead
Age & 66\selectlanguage{ngerman}±5.8 & 64\selectlanguage{ngerman}±6.2 & 63\selectlanguage{ngerman}±4.9 & \textgreater{}0,05\tabularnewline
Gender Male Female & 106 70 & 17 10 & 13 9 & \textgreater{}0,05
\textgreater{}0,05\tabularnewline
\bottomrule
\end{longtable}

\emph{Note to the Editor: The current study has been presented in
15\textsuperscript{th} Congress of Turkish Society of Cardiovascular
Surgery, 26-29 October 2018 Antalya/TURKEY and published in the Congress
Abstract Book}

Cicekcioglu F, Atilgan K, Demirdas E, Er CZ. Does LAD depression sign in
coronary angiography correlate with intramyocardial left anterior
descending coronary artery? Turk GogusKalpDamar 2018;26(Suppl 1):90.\selectlanguage{english}
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