Among the congenital anomalies of the coronary arteries, absent left circumflex artery (LCX) defect is extremely rare. Only a few cases have been reported in the literature. We report a case of a 48-year-old female who presented with a 4-month history of exertional chest pain with positive stress (treadmill) test. Conventional coronary angiogram showed a normal left anterior descending, absent LCX and a super-dominant right coronary artery (RCA) with prominent branches. Aortography also failed to show a separate ostium for the left circumflex artery. Multi-detector computed tomographic coronary angiography was performed to confirm the diagnosis of congenital absence of the LCX. It is a benign incidental finding, however some patients present with angina-like symptoms often resulting in detection of this rare anatomy on coronary angiography. Precise morphological and functional evaluation of the anomalous coronary artery is important for selecting the best treatment modality and better prognosis.

The posterior descending artery (PDA) supplying the posterior one-third of the inter-ventricular septum usually arises from the right coronary artery (RCA) or the left circumflex artery (LCX). PDA arising from the left anterior descending artery (LAD) is an extremely rare anomaly. Here we report a rare type of left dominant circulation in which a large LAD is continuing as PDA after winding round the apex in the presence of a diminutive RCA. Such a large LAD continuing as PDA is referred as “hyperdominant” or “superdominant”. A 32–year-old male chronic smoker presented with acute onset retrosternal pain of 4 h duration with profuse sweating in primary health center with electrocardiography (ECG) changes in inferior leads and was thrombolysed with intravenous streptokinase 15 lacs IU over one hour and was referred to our center for further management and coronary intervention. Coronary angiogram revealed PDA as a continuation of the LAD beyond the crux and a non-dominant right coronary as well as LCX. The LAD had plaque in mid-LAD course. Intravascular ultrasound study (IVUS) showed insignificant plaque in mid-LAD (30%). Hence, we decided to keep him on medical therapy only.

Coronary artery anomalies are clinically important as there have been reports of sudden death and fatal and non-fatal myocardial infarction associated with exercise in persons with certain types of unusual coronary anatomy. A circumflex artery originating from an ostium apart from the left main artery is one of the most common coronary artery anomalies. However, the dual origin of the circumflex artery is an extremely rare anomaly. We describe a 45-year-old female patient admitted to our tertiary care hospital with complaints of exertional dyspnea with a positive treadmill test. Angiography revealed twin circumflex arteries: one from the left main artery and the other from the proximal right coronary artery with no significant obstructive coronary lesions; hence, advised medical management.

Coronary trifurcation lesions are a complex group of lesions. Percutaneous intervention of such trifurcation lesions which involve left anterior descending artery, left circumflex artery and RAMUS artery is difficult task. Trifurcating coronary artery disease is a complex atherosclerotic process involving the origin of one or more of three side branches arising from a main trunk. The approach to treat trifurcation lesions has not been standardized. We describe a technique to percutaneously treat this lesion using routine day-to-day hardware and a unique two guide catheter technique. We present a case admitted in our hospital with unstable angina. CAG done suggestive of triple vessel disease and later PTCA was done. Staged PTCA was planned Initially RCA and subsequently Trifurcation PTCA was done for left system.No postprocedural complication was observed and then patient was discharged on third day.

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