letter to the editor

Oman Medical Journal [2020], Vol. 35, No. 6: e207

Type-IV Quadfurcation of Single Coronary Artery from the Right Aortic Sinus: New Classification

Rajesh Rajan*, Vladimir Kotevski, Mohammed Al Jarallah and Raja Dashti

Department of Cardiology, Sabah Al Ahmad Cardiac Center, Al-Amiri Hospital, Kuwait City, Kuwait

article info


Dear Editor,

We recently published a case report in European Heart Journal Case Reports.1 We proposed a modified version of Lipton’s classification, a new classification for single coronary artery (SCA), named Rajan’s and Kotevski’s TYPE-IV (R-IV-C) modified Lipton’s classification, which we describe in detail below.

In 1699, Fantoni was the first to identify the SCA.2 In 1716, German anatomist Adam Christian Thebesius first reported the existence of a SCA.3 Later, in 1841, Austrian anatomist Josef Hyrtl defined a SCA.4 In 1903, Banchi described it in an article on coronary morphology.5 In 1967, Halperin et al,6 demonstrated a SCA anomaly using conventional angiogram during an antemortem autopsy. Among the congenital coronary anomalies,7–9 SCA arising from the right is extremely rare, and its prevalence during coronary angiogram was reported as 0.02–0.05%.10 It is a condition where the entire left coronary system arise from the right coronary sinus along with the right coronary system.11

Our previously reported case of inferior wall ST-elevation myocardial infarction during primary percutaneous coronary intervention described the presence of SCA arising from the right aortic sinus that quadfurcated into left anterior descending (LAD) coronary artery, first diagonal (D1), left circumflex (LCx) coronary artery, and right coronary artery (RCA). The final angiographic appearance was similar to a trident, and we named it as TRISHULA (trident) appearance.1 Coronary computed tomography (CT) was performed to determine the anatomy and distribution of coronaries. Single coronary ostium arising from the right was confirmed and had three abnormal courses of coronary arteries. Only RCA had a normal course. LCx had a retroaortic course, LAD had pre-pulmonic course, and D1 had a sub-pulmonic (septal) course. There was no interarterial course found in this case. The TRISHULA appearance was more evident in CT coronary angiogram.

SCA arising from the right sinus has the following distribution: 1) anterior to aorta and pulmonary artery; 2) interarterial; 3) interseptal; and 4) retroaortic.12 In our case, we had all three abnormal courses except interarterial.

Based on anatomical distribution, Lipton et al,12 classified SCA into three types. Type I is rare. Here, SCA is distributed along the RCA course and continues as LCx artery, then as LAD or as left main artery, which again branches into the LAD and LCx and travels through the crux and forms the RCA. Type II is the most common, here SCA bifurcates into the right and left coronary arteries. Then the left system divides into LAD and LCx. Type III SCA which divides into RCA, LAD, and LCx.13

Our patient does not fall in any of the types described above. Hence we proposed a modified version of Lipton’s classification and named ‘Type IV (R-IV-C) Rajan’s & Kotevski’s classification of SCA’. By origin, the type of distribution can be from right (R) or left (L) aortic sinus. By anatomical distribution, it is type-IV where the SCA quadfurcates into RCA, LAD, D1, and LCx. By anatomical course, it can be categorized into A, B, P, S, and C: A – anterior to aorta and pulmonary artery (benign), B – between aorta and pulmonary artery (malignant), P – posterior to aorta and pulmonary artery (benign), S – septal course or myocardial bridge (malignant), and C – combination of diverse routes. Type IV (R-IV-C) Rajan’s and Kotevski’s cases are rare and have SCA, which quadfurcates into RCA, LAD, D1, and LCx.


  1. 1. Al Jarallah M, Rajan R, Kotevski V, Dashti R, Moustafa W. Multivessel percutaneous coronary intervention with bifurcation stenting in a quadfurcated single coronary artery from the right aortic sinus: a case report. Eur Heart J Case Rep 2019 Nov;3(4):1-4.
  2. 2. Fantoni JB. Observationes anatomico medicos selectiores. Turin, Italy: Medicos Selectiores, 1699.
  3. 3. Smith JC. Review of single coronary artery with report of 2 cases. Circulation 1950 May;1(5):1168-1175.
  4. 4. Shirani J, Roberts WC. Solitary coronary ostium in the aorta in the absence of other major congenital cardiovascular anomalies. J Am Coll Cardiol 1993 Jan;21(1):137-143.
  5. 5. Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986 May;111(5):941-963.
  6. 6. Halperin IC, Penny JL, Kennedy RJ. Single coronary artery. Antemortem diagnosis in a patient with congestive heart failure. Am J Cardiol 1967 Mar;19(3):424-442.
  7. 7. Rajan R, Kotevski V, Dashti R, Al Jarallah M. Asymptomatic congenital arteriovenous fistula arising from left circumflex artery draining into distal part of right pulmonary artery diagnosed at the 7th decade of life. IHJ Cardiovascular Case Reports 2017;1(2):86-88.
  8. 8. Al Umairi RS, Al Kindi F, Al Busaidi F. Anomalous origin of the left coronary artery from the pulmonary artery: the role of multislice computed tomography (MSCT). Oman Med J 2016 Sep;31(5):387-389.
  9. 9. Panduranga P, Nadakinamani RG. A variant of type IV dual left anterior descending coronary artery. Ann Clin Cardiol 2019;1(1):39-40.
  10. 10. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990 Sep;21(1):28-40.
  11. 11. Roberts WC, Waller BF, Roberts CS. Fatal atherosclerotic narrowing of the right main coronary artery: origin of the left anterior descending or left circumflex coronary artery from the right (the true “left-main equivalent”). Am Heart J 1982 Sep;104(3):638-641.
  12. 12. Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology 1979 Jan;130(1):39-47.
  13. 13. Roberts WC, Shirani J. The four subtypes of anomalous origin of the left main coronary artery from the right aortic sinus (or from the right coronary artery). Am J Cardiol 1992 Jul;70(1):119-121.