A very rare combination of four coronary artery anomalies in a patient with acute inferior myocardial infarction.

We present a combination of four rarely seen coronary anomalies: double right coronary artery originating from the right coronary sinus (RCS) and left main coronary artery, respectively, and separate origination of the left anterior descending (LAD) artery, circumflex artery (Cx), and septal perforator artery from the RCS. These anomalies were encountered in a 46-year-old male patient who had a previous diagnosis of spina bifida occulta and renal pelvis and presented with the complaint of chest pain of two-hour onset. He had no conventional coronary risk factors and no history of chest pain or syncope. Electrocardiography showed ST-segment elevation and cardiac enzyme levels were elevated. Coronary angiography was performed with the diagnosis of acute inferior myocardial infarction, which showed a severe stenosis in the mid portion of the LAD and total occlusion in the proximal part of the Cx. Balloon dilatation and stent implantation were performed for the Cx lesion and TIMI 3 flow was achieved. One month after the procedure, percutaneous coronary intervention was repeated for the LAD lesion and patency was achieved with balloon dilatation and stenting. Since visualization of all the coronary anomalies mentioned above posed some difficulties during coronary angiography, cardiac computed tomography angiography was also used to reveal the ostia and the courses of coronary arteries. This combination of four rare coronary anomalies has not been reported before.