This 75 year-old female has a history of hypertension and presented with acute back and shoulder pain unrelated to physical strain or injury. Her electrocardiogram (ECG) was normal and lab results were within normal limits. She was referred to a cardiologist for evaluation where her workup included both CVCT and diagnostic coronary angiography.
Both exams clearly demonstrated a high-grade eccentric mid portion stenosis of the ramus intermedius artery. This vessel appears to be relatively large; both proximally and distally, it appears within normal limits. The CVCT portion of the exam identified both calcified and soft plaque in this artery. The disproportionate artery stenosis could be related to soft plaque vessel disease.
The ramus medianus or intermedius trifurcates from the left main coronary giving rise to this middle branch in only 15% of the population. In most cases, the left main coronary artery divides into left anterior descending (LAD) and cimcumflex (LCX).