We are presenting a remarkable case of a patient with a complex coronary anomaly, with two left anterior descending arteries, alongside with anomalous origin of the main left anterior descending coronary artery (LAD) from the pulmonary artery. Each of these entities, Dual LAD and Anomalous LADcoronary artery arising from Pulmonary Artery(ALADAPA sdr.) is a rare anomaly but the combination of them, represent an extremely rare incidence, and Computed Tomography imaging plays a key role, revealing it.

A previous healthy 58 years-old patient was presented in the ER department with dyspnea on exertion and chest pain. The imaging findings after invasive coronary angiography that followedwere inconclusive andrequired further assessment with CT coronary angiography. The study was performed on a Philips Brilliance 64 slice CT scanner, and was consisted of a non-enhanced chest CT and a thin sliced contrast CT - retrospectively gated scan technique. Image interpretation was performed on a dedicated Workstation.

Left main coronary artery (LM), had normal origin from the left Valsalva sinus. It was then bifurcated into a short left anterior descending artery (LAD) and the circumflex artery (CMX). A second, longer LAD with anomalous origin from the main pulmonary artery, was found coursing in the anterior interventricular groove up to the cardiac apex causing blood steal by a left-to-right shunt through the coronary system. Anomalous Left Coronary Artery Arising from Pulmonary Artery (ALCAPA)is a rare but severe congenital cardiac anomaly and ALADAPA represent...

Although both invasive coronary angiography and non-invasive CT coronary angiography are the main diagnostic methods, CT imaging is most of the times the gold standard technique, for patient assessment, providing accurate diagnosis of coronary artery anomalies, regarding their origin and course, with detailed anatomical features.

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