Acquired coronary cameral fistulas: are these collaterals losing their destination?

Coronary Artery Fistulas: A Review of the Current and Future Roles of Imaging

Coronary artery fistulas are uncommon but clinically important entities that may produce symptoms and significant complications such as angina, myocardial infarction, coronary artery aneurysm formation, and congestive heart failure. Multiple fistula types have been recognized, and classification uses factors such as etiology, coronary artery origin, and drainage site. Both invasive and noninvasive imaging play an important role in the management and treatment of these patients, and often times, more than one modality is necessary for comprehensive evaluation of coronary fistulas. Recent advances in both functional and anatomic imaging will likely also play a growing role in fistula evaluation. The purpose of this article is to review the classification, pathophysiology, clinical presentations, imaging findings, treatment, and future imaging directions of coronary artery fistulas.

Fistula Between the First Obtuse Marginal Branch of the Left Circumflex and the Left Ventricular Cavity: A Rare Anomaly

Coronary-cameral fistulae (CCF) are rare, frequently incidental findings uncommonly noted during routine coronary angiography. They are nearly always congenital and are sometimes associated with other cardiac malformations. They can also be acquired due to trauma or chronic inflammation. These fistulae most commonly originate from the right coronary artery. The site of termination is usually the right ventricle (RV) and rarely the left ventricle (LV). Though nearly always asymptomatic and clinically insignificant, depending on their size and pressure gradient between communicating sites and terminating area, CCF can lead to pulmonary hypertension, LV dysfunction, and myocardial infarction. We describe the case of a 55-year-old woman who presented with worsening dyspnea and lower extremity edema. Transthoracic echocardiography demonstrated an ejection fraction of 55% with an RV systolic pressure of 67 mmHg. Right heart catheterization was performed to formally diagnose pulmonary hypertension and left heart catheterization was performed concurrently. This demonstrated a fistula between the first obtuse marginal branch of the left circumflex artery to the LV cavity. In this report, the authors provide a brief review of the presentation, diagnosis, complications, and management of CCF.

Two rare complications of myocardial infarction: a case report

Background

Mechanical complications following myocardial infarction (MI) have decreased in incidence due to the widespread use of early percutaneous coronary revascularization methods. We describe two rare complications as well as their natural history and uncertainties of the ideal management approach.

Case summary

Sixty-two-year-old female with multiple cardiovascular disease risk factors who had a delayed presentation of ST-segment elevation myocardial infarction and went on to develop dissecting intramyocardial haematoma progressing to ventricular septal rupture and coronary ventricular fistula.

Discussion

Intramyocardial haematoma is a rare complication of MI. It is considered to be part of the continuum of myocardial rupture which our patient eventually developed in the form of ventricular septal defect. The second rare entity in the same patient was development of a coronary ventricular fistula of the infarct-related stented, artery. The best way of managing dissecting intramyocardial haematoma is unclear with conflicting data between conservative and invasive strategies. Our patient failed the conservative approach as she progressed to frank myocardial rupture.

Spontaneous closure of an iatrogenic coronary artery fistula during recanalization of a chronic total occlusion lesion: A case report

RATIONALE

Coronary perforation leading to fistula directed to the right ventricle is a rare complication of percutaneous coronary intervention (PCI). The reported outcomes vary from a stable state to rapid deterioration.

PATIENT CONCERNS

An 86-year-old man was diagnosed with non-ST elevation myocardial infarction, and arranged to PCI procedure for the chronic total occluded right coronary artery (RCA) after coronary angiography. The guide wire went through the occluded lesion and got to the distal part of the suspected "post lateral artery", which later proved to be in the right ventricle (RV). After dilating with a 2.0 mm balloon, large amount of contrast medium leaked out from the lesion; therefore, we suspected a perforation into the pericardium.

INTERVENTION

Protamine was intravenously injected to convert the effect of heparin and the 2.0 mm balloon in diameter was dilated for about 1 h to obstruct the ejected blood flow shunting into the pericardium, but the leakage persisted. Nevertheless, the patient remained stable, and we were unable to detect an effusion in the pericardium.

DIAGNOSIS

By analyzing the angiogram and echocardiogram, we found that the contrast did not leak into the pericardium, but into the right ventricle (RV) chamber. An iatrogenic coronary artery fistula (ICAF) from the RCA to the RV was confirmed. We thus terminated the procedure.

OUTCOMES

Coronary computed tomography (CT) angiography was performed 2 days after the PCI and no abnormal shunt was found. There was no abnormal Doppler signal in the RV, either. The patient was soon discharged, and there have been no complaints of discomfort during the 10-month follow-up.

LESSONS

ICAFs from coronary to the RV always have favorable outcomes. Even like the one in this case that caused medium leakage could seal spontaneously without any additional management. Echocardiography or coronary CT angiography could be chosen as imaging options to follow-up ICAFs.

Wire Perforation or Coronary-Cameral Fistula? A Diagnostic Dilemma Complicating a Case of ST-Segment Elevation Myocardial Infarction

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Extravasation of contrast is a dreaded complication of PCI.

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Swift assessment for coronary perforation is key to avoid catastrophic complications.

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Wire perforation of coronary arteries is a known cause of coronary-cameral fistulas.

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Combined fluoroscopy and echocardiography enable more precise diagnosis.

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Most coronary-cameral fistulas are benign and require no treatment.

CT coronary angiography findings in non-atherosclerotic coronary artery diseases

Non-atherosclerotic coronary artery diseases are being increasingly recognised as causes of acute coronary events. Invasive coronary angiography frequently fails to identify the abnormalities in the proximal course of coronary arteries and coronary wall, while computed tomography coronary angiography (CTCA) allows for acquisition of more detailed information. CTCA serves as a reliable method for evaluating patients with non-atherosclerotic coronary artery diseases. The purpose of this article is to provide an overview of non-atherosclerotic abnormalities that may be demonstrated on CTCA.

Transcatheter coil embolization of iatrogenic coronary artery-left ventricle fistula after mitral valve replacement

Acquired causes of coronary fistulas are rare disorders and may develop following coronary atherosclerosis, infection, or trauma (iatrogenic). Iatrogenic coronary fistulas may be acquired secondary to surgical or nonsurgical interventions. We describe a case of an iatrogenic coronary artery-left ventricle fistula following mitral valve replacement surgery, presented with ventricular arrhythmia and heart failure. In a unique technique, we implanted three coils with the aid of a Scepter C balloon with inflation at the ostial portion of the left circumflex artery.

Multiple Small Coronary Artery Fistulas Emptying into the Left Ventricle: A Rare but Challenging Problem

A coronary artery fistula (CAF) is an abnormal communication between a coronary artery and a cardiac chamber or a great vessel. CAFs are rare based on coronary arteriography and when found they most often empty into the right ventricle and atrium and less often into the high pressure, low compliance left ventricle (LV). A patient who presented with atypical chest pain and was found to have multiple small CAFs originating from the ramus intermedius coronary artery and emptying into the LV is presented. This case highlights the challenges in providing an appropriate therapy for multiple small CAFs emptying into the LV.

Fountains in the heart-biventricular coronary cameral fistulae and bilateral coronary artery to pulmonary artery fistulae

We describe about an elderly male presented to us with effort intolerance. He was diagnosed to have multiple coronary cameral fistulae and coronary pulmonary fistulae that gives an appearance of "Fountains In The Heart". Such a combined existence of biventricular coronary cameral fistulae and bilateral coronary artery to pulmonary artery fistulae is an unforeseen entity that has never been described before in an individual.

Coronary-cameral fistulas in adults: Acquired types (second of two parts)

Acquired coronary artery fistulas (CCFs) are infrequently detected during conventional coronary angiography. To delineate the characteristics of congenital (first part) and acquired (second part) CCFs in adults, a PubMed search was conducted for papers dealing with congenital or acquired CCFs. None of the publications describing patients with coronary-vascular fistulas were included. Papers dealing with pediatric subjects were excluded. From the world literature, a total of 243 adult patients were selected who had congenital (n = 159/243, 65%) and acquired (n = 84/243, 35%) CCFs. Among the acquired types (n = 72, 85.7%) were traumatic (iatrogenic (n = 65/72, 90%), accidental (n = 7/72, 10%) and (n = 12, 14.3%) spontaneously developing in relation to severe coronary atherosclerosis or myocardial infarction. A high incidence of spontaneous resolution of iatrogenic CCFs resulting from endomyocardial biopsy or following post-septal myectomy was reported. Spontaneous CCFs associated with myocardial ischemia or infarction resolved completely in 8% of the subjects. Early surgical intervention was the treatment of choice in acquired traumatic accidental CCFs. The congenital types are addressed in a previous issue of this journal (first part). In this review (second of two parts, part II), we describe the acquired coronary-cameral fistulas.

Acquired left coronary artery fistula draining to the cardiac vein system after acute myocardial infarction revealed by CT scan

Coronary artery fistula (CAF) is a congenital condition characterized by a pathological communication between a coronary artery and a systemic vein or one of the cardiac chambers. Iatrogenic CAFs were reported to develop secondary to the rupture of coronary aneurysm. Instances of acquired CAF draining into the cardiac chambers have been described after acute myocardial infarction. Angiography is the gold standard in diagnosing CAF. We describe the case of a patient who developed a fistula draining into the middle cardiac vein on the posterior interventricular sulcus, after acute myocardial infarction, revealed by CT scan.

Congenital Left Main Coronary Artery to Coronary Sinus Fistula

Congenital coronary artery fistula is an extremely rare anomaly that may involve any of the coronary arteries and any of the cardiac chambers. We report the case of a 14-year-old female patient with a symptomatic congenital coronary fistula starting from the left main coronary artery and draining to the coronary sinus. The patient underwent surgical ligation of the fistula and had an excellent outcome.

Percutaneous closure of coronary artery fistulae in adults with intermediate term follow-up results

OBJECTIVE

Percutaneous closure of coronary artery fistulae (CAF) has become an alternative method to surgery. But there are limited data about intermediate and long-term results. In this manuscript, we aimed to review our experience about the closure of CAF with several percutaneous methods in our center.

METHODS

Seven patients who admitted to our hospital, either symptomatic or having complications attributable to CAF, were analyzed. The immediate closure results and clinical follow-up were reviewed.

RESULTS

Five patients were male (71%) and mean age was 58.3 ± 13.3 years. Five of the CAF were draining into pulmonary artery and 2 of them were draining into the right atrium. Closure of CAF was performed with coil embolization in 5 patients, detachable balloon in 1 patient, and a combination of coil embolization and glue in the remaining 1 patient. In the early follow-up, 1 patient had atrial fibrillation and 1 patient had chest pain immediately after the closure procedure; other patients discharged from hospital uneventfully. Intermediate term follow-up results (32-83 months; median, 54 months) revealed that the procedure was clinically successful in all of the patients, despite the complaint of chest pain in 3 patients and minimal flow in 1 of these patients.

CONCLUSION

Percutaneous closure of CAF is feasible and safe in anatomically suitable vessels with good results at intermediate term follow-up.

[Cardiac computed tomography in preoperative management of a congenital coronary anomaly]

We report the case of a 81-year-old man presenting with stable exercise angina pectoris. The stress test is positive and the coronaro-angiographic evaluation demonstrates a coronary fistula between the left anterior descending (LAD) artery and the pulmonary artery trunk. The mid LAD presents a significant lesion after the origin of the fistula. A cardiac computed tomography is used before surgical treatment. Coronary artery fistulas are unusual congenital or acquired coronary artery abnormalities in which blood is shunt into a cardiac chamber, great vessel or other structure. Low-pressure structure is the most common site of drainage of the coronary fistula. The clinical presentation of coronary fistulas is mainly dependent on the severity of the left-to-right shunt. Various cardiac imaging modalities are used for diagnosis and anatomical exploration before surgical or percutaneous intervention if the closure of the fistula is indicated.

Traumatic aortic dissection and coronary fistula treated with transcatheter management

An adolescent male presented with a dissection of the thoracic aorta and a left anterior descending coronary artery to right ventricular fistula following a road traffic accident. Authors report the management of this patient using a transcatheter approach for both these arterial issues, with stenting to the thoracic aorta and coil embolization of the coronary artery to right ventricular fistula as a staged procedure, along with a brief review of the literature on traumatic arterial injuries.

Left circumflex coronary artery fistula to the superior vena cava: assessment of the exact anatomy by multidetector CT

A 62-year-old woman with mild dyspnea on exertion underwent coronary angiography. A large fistula of the left circumflex artery was found but the exit site of this unusual anomaly could not be established. Contrast-enhanced multidetector computed tomography of the coronary arteries was performed which allowed clear identification of the drainage of the fistula into the superior vena cava.

Acquired coronary cameral fistula--a report of two cases

BACKGROUND

Coronary cameral fistulas (CCF) are an uncommon clinical entity; encountered occasionally during cardiac catheterization. These fistulas most commonly result from congenital abnormalities leading to neovascularization. Other possible etiologies include trauma during surgery or coronary intervention. These fistulas usually terminate directly in a cardiac chamber, most often in the right ventricle.

CASE PRESENTATION

We describe two cases of CCF where a previous coronary angiogram did not show the presence of the abnormality. Cardiac catheterization in our first patient revealed the presence of a fistula from the right coronary artery draining into the right ventricle. A coronary angiogram performed three years prior to this procedure revealed no obstructive coronary artery disease and no evidence of this fistula. In contrast our second case had an aortic valve replacement for severe aortic stenosis. A cardiac catheterization prior to the surgery revealed normal coronaries with no fistula. The patient's subsequent angiogram three years later revealed the acute marginal branch of the right coronary artery draining into the right atrium.

CONCLUSION

Coronary cameral fistula is a rare clinical entity and can be acquired during an individual's lifetime. The puzzling presentation in our first patient is unique because CCF was acquired despite lack of previous instrumentation or trauma to the right coronary artery. The exact mechanism of fistula formation is unknown. However a possible hypothesis is secondary to hypoxia-induced angiogenesis, which has not been described to date.

Coronary artery to left ventricle fistula

Background

Coronary cameral fistulas are an uncommon entity, the etiology of which may be congenital or traumatic. They involve abnormal termination of a coronary artery, usually the right coronary, into a cardiac chamber, usually the right ventricle.

Case Presentation

We describe a case of female patient with severe aortic stenosis and interventricular septal hypertrophy that underwent bioprosthetic aortic valve replacement with concomitant septal myectomy. On subsequent follow-up an abnormal flow traversing the septum into the left ventricle was identified and Doppler interrogation demonstrated a continuous flow, with a predominantly diastolic component, consistent with coronary arterial flow.

Conclusion

The literature on coronary cameral fistulas is reviewed and the etiology of the diagnostic findings discussed. In our patient, a coronary artery to left ventricle fistula was the most likely explanation secondary to trauma to the septal perforator artery during myectomy. Since the patient was asymptomatic at the time of diagnosis no intervention was recommended and has done well on follow-up.

Coronary artery fistulas: clinical and therapeutic considerations

Coronary artery fistulas vary widely in their morphological appearance and presentation. These fistulas are congenital or acquired coronary artery abnormalities in which blood is shunted into a cardiac chamber, great vessel, or other structure, bypassing the myocardial capillary network. The majority of these fistulas arise from the right coronary artery and the left anterior descending coronary artery; the circumflex coronary artery is rarely involved. Clinical manifestations vary considerably and the long-term outcome is not fully known. The patients with coronary fistulas may present with dyspnea, congestive heart failure, angina, endocarditis, arrhythmias, or myocardial infarction. A continuous murmur is often present and is highly suggestive of a coronary artery fistula. Differential diagnosis includes persistent ductus arteriosus, pulmonary arteriovenous fistula, ruptured sinus of Valsalva aneurysm, aortopulmonary window, prolapse of the right aortic cusp with a supracristal ventricular septal defect, internal mammary artery to pulmonary artery fistula, and systemic arteriovenous fistula. Although noninvasive imaging may facilitate the diagnosis and identification of the origin and insertion of coronary artery fistulas, cardiac catheterization and coronary angiography is necessary for the precise delineation of coronary anatomy, for assessment of hemodynamics, and to show the presence of concomitant atherosclerosis and other structural anomalies. Treatment is advocated for symptomatic patients and for those asymptomatic patients who are at risk for future complications. Possible therapeutic options include surgical correction and transcatheter embolization. Historical perspectives, demographics, clinical presentations, diagnostic evaluation, and management of coronary artery fistula are elaborated.

An uncommon coronary artery fistula causing survived sudden cardiac death in a young woman

Although most patients suffering from a coronary artery fistula remain asymptomatic during childhood and adolescence, many of them develop complications in adulthood due to volume overload, endocarditis or ischemia. Here we present a young woman surviving a sudden cardiac death due to myocardial ischemia with subsequent ventricular fibrillation caused by thrombosis of a coronary artery fistula deriving from the left main coronary artery. Parts of the thrombus had been embolized into the circumflex artery causing posterior myocardial infarction. The thrombosis might have been initiated by local compression from a round extracardiac mass of 3 cm with liquid and solid content located between the vena cava superior and the ascending aorta. This structure was suspected to be a hematoma which had been caused by a blunt thoracic trauma while playing soccer 2 weeks before.

Microcoil embolization for treatment of a right coronary arteriovenous fistula

A patient initially presented with anginal symptoms and a positive stress thallium test. An arteriovenous malformation in the right coronary artery causing a suspected coronary "steal syndrome" was subsequently discovered. This was treated with a microcoil embolization technique in lieu of the traditional surgical approach and this technique is described in detail. The patient had successful clinical, nuclear, and angiographic outcomes.

Assessment of congenital coronary artery fistulas by transesophageal color Doppler echocardiography

PURPOSE

Coronary angiography is the gold standard for imaging the coronary tree, but the relation of coronary artery fistulas to other structures, and their origin and course, may not be apparent. We evaluated the ability of multiplane color Doppler transesophageal echocardiography to identify coronary fistulas.

PATIENTS AND METHODS

Twenty-one patients with angiographically confirmed coronary artery fistulas were investigated by transesophageal echocardiography in four Italian hospitals between January 1997 and May 2001.

RESULTS

Transesophageal echocardiography correctly diagnosed fistulous connection in all 21 patients. This included 6 patients with connections from the left circumflex artery (into the right chambers of the heart in 5 patients, and into the left ventricle in 1 patient), 10 patients with a fistula arising from the left anterior descending artery or left main coronary artery (with drainage into the right ventricle or main pulmonary artery), and 5 patients with a fistula from the right coronary artery (with drainage sites in the lateral aspect of the right ventricle, the low posterior right atrium, or the superior vena cava). In 4 of the 21 patients, angiography did not identify the precise site of a fistula into the coronary sinus or right ventricle.

CONCLUSION

Color Doppler transesophageal echocardiography is useful in the diagnosis and in the precise localization of coronary artery fistulas.