Coronary arterial circulation is the life line for the human heart and it’s survival.Typically it is supplied by two coronary arteries, left and right coronary artery.Both, together carry about 250ml of blood every minute.( Approxinately equal to a cup of coke ! ).These coronary arteries generally divide in a predetermined fashion , and have multiple branches . It is a mystery , what decides this branching pattern
Is it like a our palmar crease ? or the cerebral gyri ?
However , it does follow a certain rule, one major coronary artery will follow the four important grooves of heart. In the left side , left main coronary artery (LM) originates in the left coronary sinus (Size varying between 1mm -20mm) and usually bifurcates into LAD and LCX. The left anterior descending artery (LAD) runs in anterior interventricular groove while , the right atrio ventriculo groove carries the right coronary artery(RCA) .Left circumflex artery (LCX) traverses the left atrio ventricular groove.The most inconstant branch is the posterior descending artery (PDA) which runs in the posterior interventricular groove.PDA can arise from either RCA, LCX or both or even from LAD.
The major branches of LAD are called diagonal and septal while the branches of LCX are called obtuse marginal(OM).There can be two to three diagonal and OMs.
What is ramus intermedius coronary artery ? What is the incidence of Ramus ?
The left main coronary artery instead of bifurcating into two , it trifurcates into three vessels.(LAD, LCX, Ramus)
The real incidence could vary betweenn (10% to 30%) depending upon the series.
What course it takes ?
It generally goes in the angle between the LAD and the LCX.It may either behave like a large OM or a diagonal branch.It supplies the lateral free wall of the LV many times.The peculiarity of this vessel is it does not run in a anatomical groove .It simply slides over the free surface of LV.Rarely, a very abnormal course of ramus, criss cross the aorta and pulmonary artery .
How common is atherosclerosis within Ramus ?
We don’t know yet. But it is very likely since it is an early branch from left main, it might have a predilection for atherosclerosis as like LAD or LCX ostium.In fact now we recognise more of trifurcation lesions involving three branches of left main .
What would be the ECG finding if a large ramus is the culpirit vessel during STEMI ?
This scenario could be rare.
ACS in ramus could present as ST elevation in 1/Avl /V5,V6
- Lateral MI
- Apical MI
- High lateral MI
But it is realised , whenever the ECG changes are not fitting with typical ASMI or a lateral MI one should suspect a ramus lesion
What is the significance of ramus for an interventional cardiologist ?
PCI in ramus is a rare opportunity for a cardiologist .The issue here is, if ramus is involved adjacent LAD and LCX is also likely to be involved .So it would logically be a multivessel , complex angioplasty.Isolated ramus lesion could be tackled easily.Another issue here could be ,since this vessel is not within any anatomical groove stent deployment would have a poor support and prone for mobilisation and migration .
Thank you so much for this very helpful site!
I had this artery stented on 1/1/12 and now find it interesting that it may be prone to migration. Excellent site.
I also had this artery stented. I had ST elevation in leads I and V6 as you described. I was treated with a single drug eluting stent and have been pain free since the procedure.
I had 2 stints in the ramus in 2003, and in 2004 had 3 more stints put in, after the 3 stents were put in i went home for 1 day and had what they called a controlled heart attack which lasted 2 days when the stints collapsed. They told my family that there was nothing they could do but watch to see how much damage was done to my heart.
Hi this is Dr Sayed Marei ,
Thank you for these useful information about the ramus intermedius branch , I started recently Cardiac imaging by using CT and MRI in my Institution . This week I found a 53 year male patient had two Rami intermedius branches showing atherosclerotic changes with areas of significant stenosis , in addition to similar changes in the other coronary arteries by MDCT scanner. My question is how often the incidence of double rami , as I feel it is extremly rare. Thanks
Hi Dr Sayed
Thank you for your comment.Double Rami should be extremely rare as you say. I haven;t seen one.
but i would like to know how was the circumflex and OMs in the patient .
I will look for any further information on this and post later.May I know from which place and hospital you hail from?
Regards
Venkatesan ,Chennai India
i had my Ramus artery stinted 11/01/18. my symptoms were indigestion then eventually pain down my right arm to my finger tips. I had 100% blockage, my cardiologist showed me the images and told me about the Ramus artery and told me I actually had one big Ramus and another Half sized one. Interesting. I have had nonspecific st t changes since 1998. all the other vessels had no or 5 to 15% “blockage” my lab values are essentially normal, bp normal, however i did lose 100 pounds over the last few years, i’m sure that helped.
thanks suzanne, very interesting article
On October 15th I suffered a MI .It was all due to a 98 % blockage in the Ramus Arterie. But for months prior I had Soaking wet sweats which lead to heart palpitations ,like my heart was going to beat out of my chest…I have cardiomyopathy…(Ehlers Danlos Syndrome,Vascular type 4 ) Addisons ,Diabetes ,Seizure disorder etc, The ER just kept telling me that it was just ANXIETY and sent me home. Is this NORMAL ?? The Stent I had put in was NO DRUGS on /in it …….How long will it stay in place having eds and all ?How do you know if it migrates ? AS I had chest pains 2 days ago …prior I have had NO PAIN SINCE THE MI ! PLEASE help as I am very complicated medically and we have to do a lot of the research on our own …Thank you for taking the time to respond to this most important matter…Nadine
Hi Mr Nadine
You seem to have some symptoms which is not related to your heart condition.Relax and follow the advice of your doctor.dont get anxious about the stent behaviour and other issues.i have just discussed a rare theoretical possibility meant to stimulate academic discussion for cardiologist.
So please be confident and the drugs you take will protect you fully against any cardiac events.
Have a great life which iam sure you will
Bye
Dr Venkatesan
Chennai
India
Thank you for taking the time to reply..by the way I am a Mrs. …I have been involved in the medical field for well over 30+ years when my daughter was diagnosed with cancer.So I do have quite the understanding of the medical terminology along with how our bodies work .being so complicated with several co-morbidities I have had to research a lot on my own ,as many people who suffer EDS..Ehlers -Danlos type 1V ,vascular that bleeds into several other types that includes dislocations of bones ,joints,organs etc. then add on Addisons ,Diabetes 2 etc. etc. any ways thank you for your reply.I just thought that you seemed like a Dr. who thinks outside of the box.sorry to have bothered you ! Mrs.Nadine Faddoul
Hi Dr.Venkatesan
Recently I underwent stenting as I had double coronary artery disease.
I had 80% stenosis in LAD Type vessel. Proximal 80% stenosis at bifurcation,
Distal -Norma, l Diagnols- Normal.
septa1- Ostio Proximal 90% stenosis
Here a stent of size 3.5x 38 mm was inserted.
Ramus Intermedius: Proximal 90% stenosis dividing in to branches
Here a stent measuring 2.5 x 18 mm was inserted
LCX- Non dominant
Proximal and Distal Normal
RCA- Dominant
Proximal- Minimal disease
Mid-Normal
Distal-Normal
PDA and PLXB Normal
You have mentioned the stent in Ramus is prone to mobilisation and migration
due to the anatomical structure.
Can you elaborate. What is the prognosis
Rgds
I think i need to clarify .The risk of migration is theoretical .It doesnt happen once deployed. .Need not bother.
Hi Dr. Venkatesan:
I experienced a heart attack caused by blockage in my LDA. My Doctor also found my OM completely blocked but did not stent it. I’m very worried about this because no straight answer is being supplied. Is my heart going to get weaker on a daily basis unless my OM is stented. THanks so much for your time and answer.
Ron LaRusso
Florida, USA
Hi Mr. Ron Larusso,
I think you need not bother about a blocked artery much , as long as it doesnt cause symptoms and the same area gets blood supply by visible and invisible channels.Please Consult your cardiologist. I can assure you thousands of patients doing active work with more than one or two blocks.
Dr Venkatesan
Chennai.India.
Hi Dr.
Interesting article. I recently had a CT Angio and they detected moderate blockage of 40-50% in my LDA. They also noted the trifurcation from my LM. All other arteries were clean. I was freaked out a bit about the blockage but my doctor said medicine and a healthy life style should keep me healthy and I should not worry to much about the blockage. Needless to say, I am worried. He did mention that the trifurcation is a blessing for me. Is that true?
Thanks!
John
The doctor said I have a ramus artery is this good to have because they say only 20% of the population has it they said mine is large and clear I took up angiogram test and it showed that I had that. So is it better to have a ramus artery or not thank you.