Imaging and physiologic characteristics of coronary kinks

Coronary kinking represents an underrecognized diagnosis which typically arises as a complication of invasive cardiovascular procedures but may also be non-iatrogenic and nonatheromatous. Determining the etiology of coronary kinking poses a diagnostic dilemma with limited guidance in the medical literature. A stenotic lesion on invasive coronary angiography (ICA) may be attributable to intrinsic causes, such as atherosclerosis, fibromuscular dysplasia, coronary vasospasm, spontaneous coronary artery dissection, coronary kinks, and severe tortuosity, or extrinsic causes such as myocardial bridging. Lesions that appear angiographically atypical can be further elucidated with intracoronary imaging using intravascular ultrasound (IVUS) or optical coherence tomography (OCT), which help distinguish coronary kinks from other mimicking etiologies. Coronary kinks have the potential to cause ischemia, arrhythmia, and other structural complications, underscoring the importance of early and accurate detection. In this review, we summarize and appraise published data on coronary kinks. We also share a diagnostic schema on how to investigate coronary kinks with noninvasive and invasive techniques.