239 CASE REPORT A Rare Type of Coronary Anomalies: Twin Circumflex Arteries Nadir Bir Koroner Arter Çıkış Anomalisi: İkiz Circumflex Arter Cihan Öztürk, Melik Demir, Burcu Çakır, Ahmet Kenan Yalta Trakya University Faculty of Medicine, Department of Cardiology, Edirne, Turkey ABSTRACT Coronary artery anomalies have been mostly diagnosed incidentally in clinical practice. In this context, anomalous origin of the circumflex (Cx) artery has been relatively frequent compared with other anomalies. However, twin circumflex (Cx) arteries have been very rarely encountered to date. In a previous study, it was reported that the incidence of Cx arteries originating from the left and right coronary sinuses ranged from 0.19% to 0.29%. Clinically, this anomaly is generally considered a benign pathology. However, in the case of a possible acute coronary syndrome or unstable angina pectoris, it may cause difficulties in diagnosis and treatment. In this paper, we report a 58-year-old male patient admitted with angina pectoris in whom the coronary angiogram (CAG) demonstrated twin Cx arteries (two separate arteries stemming from the left and right coronary systems) along with a critical stenotic lesion in the right coronary artery (RCA). Key words: Coronary artery anomalies, twin circumflex arteries, circumflex anomalies ÖZET Koroner arter anomalileri klinik pratikte çoğunlukla tesadüfen teşhis edilmektedir. Bu bağlamda sirkumfleks (Cx) arterin anormal orijini diğer anomalilere göre nispeten daha sık görülmektedir. Ancak bugüne kadar ikiz sirkumfleks (Cx) arterlere çok nadir rastlanmıştır. Daha önce yapılan bir çalışmada sol ve sağ koroner sinüslerden kaynaklanan Cx arterlerin görülme sıklığının %0.19 ile %0.29 arasında değiştiği bildirilmişti. Klinik olarak, bu anomali genellikle iyi huylu bir patoloji olarak kabul edilir. Ancak olası bir akut koroner sendrom veya kararsız angina pektoris durumunda tanı ve tedavide zorluklara neden olabilir. Bu yazıda, anjina pektoris ile başvuran ve koroner anjiyografide (KAG) ikiz Cx arterleri (sol ve sağ koroner sistemlerden çıkan iki ayrı arter) ile birlikte sağ koroner arterinde (RCA) kritik bir stenotik lezyon gösteren 58 yaşında bir erkek hasta sunuldu. Anahtar Kelimeler: Koroner Arter Çıkış Anomalisi, İkiz Circumflex Arter, Circumflex Anomalisi INTRODUCTION Anomalous origin of the circumflex (Cx) coronary artery has been occasionally encountered on coronary angiogram (CAG) during daily clinical practice. However, double or twin Cx arteries (each originating from a separate ostium) have been very rarely reported to date(1, 2). In this paper, we report a case of twin Cx arteries (one artery arising from the left main coronary artery (LMCA) and the other from the right coronary system). CASE REPORT A 50-year-old male presented with exercise angina. His electrocardiogram (ECG) demonstrated no evidence of ischemic changes. Physical examination was unremarkable. He also had hypertension as a risk factor. CAG was performed due to a clinical suspicion of unstable angina pectoris. The LMCA, left anterior descending (LAD), and circumflex artery (LCx) arteries were normal (Figure 1A). However, a second Cx artery (RCx) stemming from the right sinus of Valsalva was opacified during CAG of the right coronary artery (RCA)(Figure 1B). There was also a 90% stenosis involving the 2nd segment of the RCA that was successfully managed with the implantation of a drug- eluting stent (Figure 1C). There was no ischemic change in the patient's ECG (Fig. 1D) and patient was discharged after an uneventful clinical follow-up. DISCUSSION Coronary artery anomalies have been clinically silent in most cases. However, they also have the potential to Corresponding author: Cihan Öztürk, Trakya University Faculty of Medicine, Department of Cardiology, Edirne, Turkey E-mail: dr.cihanozturk@gmail.com Eskisehir Med. J. 2022; 3(2):239-241. Received date:21.02.2022 Accepted date:20.06.2022 Authors: Cihan Öztürk (ORCID: 0000-0001-8694-1693), Melik Demir (ORCID: 0000-0003-1711-6707), Burcu Çakır (ORCID: 0000-0002-0190-7670), Ahmet Kenan Yalta (ORCID: 0000-0001-5966-2488)