Vieussens' Arterial Ring: Historical Background, Medical Review and Novel Anatomical Classification

Abstract

In coronary artery disease, the presence of Vieussens' arterial ring (VAR), a ring-shaped anastomosis between the conus branch of the right coronary artery with the left anterior descending artery (LAD), will allow blood flow to return to the obstructed coronary system. We have conducted a literature review, aiming to collect all the existing information about the documented VAR cases and any related pathological conditions. A total of 54 studies entered the review, including 56 patients. The mean age of the patients was 56.12 ± 16.2 years. Angina was present in 53.6% of the patients, with 7.2% of the cases being asymptomatic. Coronary artery disease outweighed (58.9%) as the patients' most frequent diagnosis. We propose a novel VAR anatomical classification, based on the sites of origin and termination of its course, with six distinct types, for a better understanding and surgical management of VAR. Type IA, originating from the conus branch and terminating in the proximal segment of the LAD was most frequently reported (51.8%). The recognition and the subsequent evaluation of the ring's anatomy and course are crucial for a customized clinical intervention. When right and left coronary angiographies fail to reveal any collateral circulation, selective conus artery catheterization should be in order. The proposed classification offers a manageable and comprehensive context for the assessment, evaluation and planning of therapeutic strategies of VAR and sets a new terminology frame for treatment guidelines.

Keywords: anatomic variant; anatomical classification; coronary artery disease; coronary collateral circulation; raymond de vieussens.

Figure 1. Raymond Vieussens and his work "Traité Nouveau de la Structure et Des Causes Du Mouvement Naturel Du Coeur".

Colourized xylography from the first edition of Raymond’s work in Toulouse 1715 titled "Traité Nouveau de la Structure et Des Causes Du Mouvement Naturel Du Coeur" (New Treatise on the Structure and Causes of the Natural Movement of the Heart) published by Jean Guillemette (left side) and his work "Nouvelles Decouvertes Sur Le Coeur" (New Discoveries about the Heart) [7] published by Laurent d'Houry in Paris 1706 (copyright protection has expired).

Figure 2. PRISMA flowchart of the article selection process

PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Figure 3. Distribution of the symptoms resulted in hospital admission

Most reported symptoms related to Vieussens’ arterial ring.

Figure 4. Summary of diagnoses made in the 56 Vieussens’ arterial ring cases

Diagnosis distribution of the reviewed cases. CAD = coronary artery disease, CAF = coronary artery fistula, LMCA = left main coronary artery, RCO = right coronary ostium, VAR = Vieussens’ arterial ring

Figure 5. Vieussens’ arterial ring; Proposed anatomical classification and clinical significance.

(A) The ring’s anatomic course is determined from its origin, either from the conus branch or from the isolated conus artery and its site of drainage to the LAD, either proximal, medial or distal. Accordingly, six types of VAR are formed, with type IA being the most common one. (B) In coronary artery disease of either RCA or LAD, VAR can naturally bypass the obstructions, providing a life-saving collateral network towards the occluded coronary system. Also, its use during the percutaneous intervention can confirm the intraluminal wire position after crossing and provide an alternative to the anterograde approach in case of crossing failure. LAD = left anterior descending artery, RCA = right coronary artery, VAR = Vieussens’ arterial ring

Figure 6. A possible role of Vieussens’ arterial ring (VAR) in coronary interventions

(A) In the absence of VAR, a retrograde approach for a totally occluded (arrows) left anterior descending (LAD) artery may fail because of tortuous, perforated (red haziness) or non-interventional collaterals (green circle). (B) Similarly, in the absence of VAR, both retrograde and antegrade approaches may fail in cases of coexisting distal right coronary artery (RCA) occlusion (green circle, arrow) thus precluding collateral formation and distal LAD visualization for safe guidewire advancement. (C) On the contrary, when VAR is present, it can be used as a path for retrograde guidewire advancement to occluded LAD or (D) for LAD visualization in the antegrade attempt in case of coexisting distal RCA occlusion. dotted line = guidewire; LM = left main; LCx = left circumflex artery