there is a great physiological variability in origin , course , and distribution of these vessels , and we can assure that do not exist two equal coronary trees . coronary artery anomalies are often not associated with clinical signs , symptoms , or complications , and they are usually compatible with normal heart development and function , even allowing normal physical activity . nevertheless , this condition can be fatal , typically in young and previously  healthy  athletes . in fact , as an exception to angina and syncope , sudden death is frequently the only manifestation of anatomic subset . according to the sudden death committee of the american heart association , coronary artery anomalies may also be associated with congenital heart diseases such as great arteries transposition , single ventricle , or tetralogy of fallot . however , coronary artery anomalies are more often discovered as incidental findings at the time of coronary angiography ( ca ) or autopsy . according to the literature , the clinical relevance of coronary artery anomalies is closely related to the functional ability of anomalous vessels to provide adequate blood supply to the myocardial tissue , with or without significant obstructive coronary disease . we present the case of a 54 years old woman , who was a smoker and was affected by obesity , type 1 diabetes , and hypertension . eight years before , she had undergone surgical aortic valve replacement with mechanical aortic valve . the patient was admitted to hospital to perform elective surgery for ascending aortic aneurysm . in the last 6 months , she experienced several episodes of typical angina and chest tightness not related to exertion or emotional stress . echocardiography showed global and regional left ventricular contractile function ( left ventricular ejection fraction 56% ) , mild mitral and tricuspid regurgitation , and ascending aortic aneurysm with maximum diameter of 71 mm . the patient was in coronary angiography ( ca ) . at ca , there was no significant coronary artery stenosis or dynamic obstructions , but we incidentally found a congenital coronary anomaly in the form of peculiar dual left anterior descending artery ( lad ) anatomy . lad arising from the left sinus of valsalva was short and gave rise to one septal branch , a little intermedius branch , and one diagonal branch [ figure 1 ] . the left circumflex artery ( lcx ) was aplastic [ figure 2 ] and the right coronary artery ( rca ) was dominant and normal in origin and course [ figures 3 and 4 ] . a second lad was seen arising from the right sinus of valsalva , with a third ostium different from rca [ figure 5 ] . this second lad was long , run over the right ventricle , and gave rise to septal and diagonal branches , supplying the mid and distal territories of septal , antero - lateral wall , and apex [ figure 6 ] . short lad arises from the left sinus of valsalva and gives rise to one septal branch , little intermedius branch , and one diagonal branch circumflex artery ( lcx ) is aplastic , as shown in the left caudal angiographic projection right coronary artery ( rca ) is normal in its origin and course right coronary artery ( rca ) is normal in its origin and course long lad arises from the right sinus of valsalva with a separate ostium , different from rca . this lad is longer than the first , runs on the right ventricle , and gives rise to septal and diagonal branches , supplying the mid and distal territories of septal , anterior , lateral wall , and apex overlapping figures 1 and 5 , we can see the entire course of lad along interventricular sulcus to the apex this specific anatomy , for some features , could be seen in type iv dual lad , referring to spindola - franco et al . moreover , in our case , we can identify a number of anatomical peculiarities which might be useful to define a distinct coronary artery anomaly . among the coronary arteries , anomalies like dual lad anatomy are rare , in particular , the anomalous origin of lad from the right sinus of valsalva or proximal portion of rca is extremely rare , ranging between 1.2% and 6.1% of all coronary anomalies . have proposed an angiographic classification for dual lad , consisting of four types of lad anomaly . in the first three types , lad is divided into two branches : a short branch that supplies the proximal third of the septum and a long branch that can take several courses as shown below . type i : running in the anterior interventricular sulcus ( aivs ) , the short lad is generally the source of all the major proximal septal perforators . the long lad also runs in the aivs , descending on the left ventricular side of the aivs , and then reentering the distal aivs in order to reach the apex.type ii : the short lad is the same as in type i. the long lad descends over the right ventricular side before reentering the aivs.type iii : the short lad is consistent with that described in types i and ii . the long lad travels intramyocardially in the ventricular septum.type iv : high in the aivs , a very short vessel is formed by the lad proper and the short lad . from this vessel , type i : running in the anterior interventricular sulcus ( aivs ) , the short lad is generally the source of all the major proximal septal perforators . the long lad also runs in the aivs , descending on the left ventricular side of the aivs , and then reentering the distal aivs in order to reach the apex . type ii : the short lad is the same as in type i. the long lad descends over the right ventricular side before reentering the aivs . type iii : the short lad is consistent with that described in types i and ii . type iv : high in the aivs , a very short vessel is formed by the lad proper and the short lad . from this vessel , , we report a type of dual lad anatomy that is not included in the angiographic classification previously proposed . it could be considered as a variant of type iv , with anomalous lad origin from an ostium located in the right sinus of valsalva , separated by the right coronary ostium . furthermore , the short lad is a unique vessel with the left main ( lm ) , without lcx wich appears aplastic . isolated dual lad , in absence of significant stenosis , has usually little clinical relevance . in fact despite its anomalous anatomy , functional status is often not compromised and does not occur flow reduction , except for rare conditions associated with its route , like ab extrinseco compression , inter - arteriosus course between aorta and pulmonary artery , intramyocardial tract , kinking , or pivot point . we describe for the first time in the literature , a dual lad anomaly associated with lcx aplasia it would be important to know this anatomical subset , not only for its peculiar anatomical features , but also , above all , for the implication in terms of any surgical or interventional coronary approach when it should prove necessary .
coronary artery anomalies are uncommon disorders . according to the literature , 1% of the general population 
 is affected by a coronary artery abnormality . 
 coronary artery anomalies are often not associated with clinical signs , symptoms , or complications ; nevertheless , they can be associated with congenital heart diseases and lead to sudden death . however , these anomalies are more often discovered as incidental findings at the time of coronary angiography or autopsy . 
 the clinical relevance of coronary artery anomalies is closely related to the functional ability to provide adequate blood supply to the myocardial tissue . 
 we describe a complex left coronary artery anomaly , not previously reported in medical literature , involving origin , course , and distribution of this vessel .