Kugel's artery

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An uncommon variant of coronary arterial anatomy, Kugel's artery was originally described as an anastomotic communication between branches of the proximal left circumflex artery with the distal right coronary artery. These coronary trunks often communicate indirectly through atrial anastomotic networks; Kugel's artery is distinguished by its size and characteristic course .

Terminology

Initially described as the “arteria anastomotica auricularis magna” due to its relatively large luminal diameter and its perceived role as a crucial component of the coronary circulation. The eponym now refers to an artery which connects the proximal left circumflex or right coronary artery with the distal right coronary or left circumflex artery.

Epidemiology

Its reported incidence differs between studies, with one recent publication noting its presence in 6% of the population. It originated from the proximal left circumflex artery and ended in the right coronary artery in two patients; from the right coronary artery and ended in the same artery in a further two patients; from the left circumflex artery and ended in the same artery in one patient; and from the right coronary artery through the sinus node artery, ending in the left circumflex artery, in one. Of note, a collection of more diminutive vascular anastomoses in the interatrial septum is usually present, which connects the coronary trunks in the absence of a distinct Kugel's artery .

Gross anatomy

Origin
  • left circumflex artery (LCx)
    • most common variant proximal LCx to distal right coronary artery
    • less commonly will end in the distal LCx
  • right coronary artery (RCA)
    • most commonly terminating in a more distal segment of right coronary artery
    • may also communicate with the left circumflex artery via the sinoatrial nodal artery 
Course

After branching from the LCx or RCA, Kugel's artery first traverses the atrioventricular groove posterior to the aortic root, subsequently traveling within the basal interatrial septum. It will then cross the septum adjacent to its attachment with the membranous interventricular septum. Its position in relation to the aortic root and the direction which it crosses the interatrial septum to meet its point of anastomosis is based on the vessel's origin and termination .

Variant anatomy

Variable branching patterns can be present:

  • anastomosis with the right coronary artery
    • will course posterior and to the right of the orifice of the coronary sinus
    • meets the distal right coronary artery several millimeters to the right of the crux
  • anastomosis with the left circumflex artery
    • will travel inferoposteriorly in relation to the orifice of the coronary sinus
    • terminates in the circumflex several millimeters to the left of the crux