A few strategies offer the possibility of growing additional redundant blood vessels, though this is far from rigorously proven. Intermittently provoking hematopoietic stem cells to leave the bone marrow via CXCL12 upregulation, for example. Humans are not completely uniform in their major blood vessel networks, there are variant populations with more redundancy. The value of that greater redundancy is illustrated here by a look at a patient possessing a Kugel's artery, a rare additional vessel that can allow survival in cases of obstructed coronary arteries due to the progression of atherosclerosis. Redundancy in blood vessel networks is a poor substitute for addressing the causes of atherosclerosis, such that no-one suffers blocked vessels, but if redundancy can be engineered, then it would be a benefit.
Kugel's artery is defined as a rare anatomical variant of the coronary artery vascular bed consisting of an anastomotic connection between branches of the right coronary artery (RCA) and/or left circumflex artery (LCX). Kugel's artery has been reported to have an incidence of 6% in the general population. The presence of this anastomotic communication may play a pathophysiological role in a patient with a right dominant coronary circulation and an underlying coronary artery disease (CAD) affecting the right coronary system. There exist only a few reported cases of Kugel's artery with the pathophysiological relationship in CAD remaining unclear. Herein, we present a case with multivessel occlusion myocardial infarction found to have anomalous vascular anastomosis between the proximal RCA and distal segment of the same artery.
A 67-year-old African American male with no significant past medical history presented to the emergency room for an out-of-hospital witnessed cardiac arrest. In this case, the Kugel's artery was found to connect the proximal RCA to the branches of the distal RCA. The patient was found to have inferior anterolateral myocardial infarction on EKG and coronary angiogram revealed complete total occlusion of RCA and obtuse marginal. With total occlusion of the RCA one would expect to have a clinically significant myocardial infarction earlier in life, however, because of the patent Kugel's artery, the territory of RCA had viable blood supply and the presentation was most likely due to occlusion of the second obtuse marginal branch of the LCX. This bears out the observation by previous studies that collateral circulation was not seen in angiography until the degree of arterial occlusion is greater than 90%.
A favorable long-term prognosis is associated with good collateralization in patients with angiographically-proven single or double vessel CAD. Based on our patient's EKG and coronary angiogram findings, his acute presentation was most likely due to myocardial infarction in the LCX territory. He denied previous cardiorespiratory symptoms which may indicate myocardial viability in the distribution of RCA maintained by the Kugel's artery. Understanding the existence and significance of Kugel's artery and the anastomotic network cannot be overemphasized. The presence of an anomalous vascular connection bypassing an area of epicardial vessel occlusion may be a lifesaving pathophysiological finding that maintains myocardial perfusion and viability.