It is rare for an accessory left anterior descending artery to be the single coronary artery anomaly in adult with severe atherosclerosis. An off-pump coronary artery bypass was performed electively for the patient. We indentified that the accessory left anterior descending artery, accompanied by a little portion of the left anterior descending artery, ran in the anterior interventricular groove to the apex. Four vessel-anastomoses, including the left internal mammary artery to the accessory left anterior descending artery, were made, and the patient finally had an uneventful recovery. Careful study of the image in coronary angiography before the procedure and attentive examination of the plaque during the operation is the key to discriminating the variant vessel.
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