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The Ramus Intermedius: A Bridge to Survival in the Setting of Triple-Vessel Total Occlusion

Aleksan Khachatryan1, Robert Td Chow2,1, Mukta C Srivastava3

  • 1Department of Internal Medicine, University of Maryland Medical Center, Midtown Campus, Baltimore, USA.

Cureus
|July 1, 2024
PubMed

Insights

The ramus intermedius (RI) artery may offer a protective role in coronary artery disease. This case highlights its potential to sustain myocardial blood supply during severe occlusions, improving survival.

Area of Science:

  • Cardiovascular Medicine
  • Interventional Cardiology
  • Anatomical Variations

Background:

  • Coronary artery disease (CAD) is a leading global cause of mortality.
  • The left main coronary artery (LMCA) typically bifurcates into the LAD and LCX, but may trifurcate with a ramus intermedius (RI).
  • The clinical significance of the RI remains debated, with conflicting data on its association with atherosclerosis and myocardial protection.

Observation:

  • A 58-year-old male presented with acute coronary syndrome and cardiogenic shock due to left anterior descending (LAD) artery occlusion.
  • The patient had chronic total occlusions of the right coronary artery and left circumflex (LCX) artery.
  • A patent ramus intermedius (RI) served as the sole blood supply to the myocardium.

Findings:

  • The ramus intermedius (RI) provided critical collateral circulation, sustaining myocardial viability despite extensive coronary artery disease.
  • Literature review of similar cases suggests a potentially protective role for the RI in enhancing survival during severe coronary occlusions.
  • The RI's contribution to survival in this case underscores its importance in myocardial perfusion.

Implications:

  • The ramus intermedius (RI) may represent a significant collateral pathway, potentially improving outcomes in patients with complex coronary artery disease.
  • Further research is warranted to fully elucidate the role of the RI in CAD pathophysiology and clinical management.
  • Recognizing and understanding the anatomical variant of the RI is crucial for accurate diagnosis and treatment strategies in cardiology.

Keywords:
atherosclerosiscardiogenic shockcoronary artery diseasecto: chronic total occlusionendothelial shear stressleft heart catheterizationramus intermediusst-elevation myocardial infarction (stemi)trifurcationva-ecmo

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