Anomalous right coronary artery stemming from left coronary sinus and malignant interarterial course in a middle-aged woman: a case report and review of diagnostic and surgical management

An anomalous right coronary artery (RCA) arising from the left coronary sinus with an interarterial/intramural course can cause exertional ischemia and, rarely, sudden death. Functional testing and coronary CT angiography (CCTA) are key for diagnosis and risk stratification. We report the case of a 46-year-old woman presenting with exertional dyspnea and jaw discomfort. She had no conventional cardiovascular risk factors aside from hyperlipidemia and a family history of premature coronary disease. Exercise treadmill testing and myocardial perfusion imaging revealed inducible ischemia. Coronary computed tomography angiography demonstrated an anomalous RCA arising from the left coronary sinus with an interarterial and intramural course between the aorta and pulmonary artery. Surgical consultation confirmed a malignant anatomical variant, and the patient underwent successful coronary artery bypass grafting (CABG) with complete symptom resolution. This case underscores the importance of considering congenital coronary anomalies in the differential diagnosis of exertional angina, especially in patients without atherosclerosis or major cardiovascular risk factors. Functional and anatomical imaging are essential for risk stratification. CABG remains an effective treatment for high-risk anomalies when direct reimplantation is not feasible. In symptomatic patients with demonstrable ischemia and high-risk anatomic features, surgery provides excellent outcomes. Early recognition using complementary functional and anatomic imaging is essential.