Anomalous Coronary Arteries from the Opposite Sinus of Valsalva: A Case Series and Comprehensive Review

Anomalous coronary artery from the opposite sinus (ACAOS) is a rare congenital abnormality that may be encountered during routine coronary angiography. Clinical manifestations vary depending on the subtype and anatomical course of the anomaly; however, certain potentially malignant trajectories may result in myocardial ischemia, infarction, or sudden cardiac death, particularly in young individuals and athletes. Multiple imaging modalities including coronary angiography, CT angiography, and cardiac MRI are useful in the evaluation of coronary artery anomalies. Accurate delineation of the origin and course of the anomalous vessel is essential for risk stratification and therapeutic planning. Performing percutaneous coronary intervention (PCI) in patients with ACAOS can be technically challenging and often requires modifications in guide catheter selection and procedural technique. In this review, we present a series of patients with anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). We discuss the anatomical variations and courses of these anomalous vessels as defined by angiographic and advanced imaging findings. Particular emphasis is placed on guide catheter selection, technical challenges encountered during selective cannulation, and the strategies employed to achieve successful engagement and intervention.