A Tale of Two LADs (Left Anterior Descending Arteries): Type IV LAD as a Rare Coronary Anomaly

A dual left anterior descending (LAD) artery is angiographically defined as the presence of two distinct coronary arteries supplying the LAD territory. It represents a rare coronary artery anomaly in the general population but may have important implications during the evaluation and management of acute coronary syndromes (ACS), percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Accurate recognition of this variant is essential to avoid misinterpretation of coronary angiograms, incomplete revascularisation, and procedural complications. The objective of this case report is to describe the clinical presentation, angiographic characteristics, and management of two patients diagnosed with type IV dual LAD anomaly in the setting of ACS, one presenting with ST-elevation anterior wall myocardial infarction (STEMI) and the other with non-ST-elevation myocardial infarction (NSTEMI). The report also aims to highlight key diagnostic clues and practical considerations for interventional cardiologists and cardiac surgeons when encountering this rare anomaly.