Coronary artery fistula in a patient with coronary artery disease: evaluation by coronary angiography and multidetector computed tomography

Complex Coronary Artery Fistula in a Young Adult: Not Seeing the Wood for the Trees

Coronary artery fistulas (CAFs) represent rare congenital anomalies that exhibit a wide range of clinical implications and a heightened risk of complications. It is imperative to accurately identify and delineate these fistulas to avoid missed diagnoses and to recommend suitable therapeutic measures. We present the case of a 46-year-old obese woman who was hospitalized for chest pain associated with palpitations. Clinical examination and ECG results were within normal limits. A 24-hour ECG holter revealed paroxysmal atrial fibrillation. Transthoracic echocardiography revealed a systolodiastolic aliasing originating from the aorta and coursing along the right atrium. Transesophageal echocardiography and coronary angiography confirmed this finding. The diagnosis of a voluminous and tortuous coronary-cameral fistula was established through coronary CT angiography with 3D reconstruction images. A positive stress test indicated the need for surgical closure, given the size and aneurysmal nature of the fistula. However, the patient unfortunately passed away two days after the surgery. This case highlights the critical need for precise identification and management of CAFs. The patient's unfortunate post-surgical outcome underscores the complexity and risks associated with these anomalies, emphasizing the ongoing need for improved treatment strategies and research in this area.

Dual Coronary-Pulmonary Fistula Firstly Found at Routine Doppler Echocardiogram

Congenital coronary-pulmonary fistulas (CPFs) are defined as an abnormal direct communication between one or more coronary arteries, with a cardiac or thoracic structure bypassing the capillary network. We report the case of a 73-year-old male, with a history of hypertension, asymptomatic for angina and dyspnea, who was referred for routine clinical control. Echocardiogram unexpectedly showed the presence of diastolic flow from the pulmonary trunk in parasternal short-axis view. Pulsed-wave Doppler confirmed the presence of diastolic flow and displayed the typical coronary flow pattern. Coronary angiography hence showed the presence of dual CPFs originating from the second segment of the left anterior descending coronary and the right coronary arteries. Careful routine Doppler echocardiograph examination may raise the suspicion of CPF in case of otherwise unexplained symptoms and may represent a simple, easy, repeatable tool for the first suspected diagnosis and follow-up of CPFs.

Unilateral and multilateral congenital coronary-pulmonary fistulas in adults: clinical presentation, diagnostic modalities, and management with a brief review of the literature

BACKGROUND

Congenital coronary-pulmonary fistulas (CPFs) are commonly unilateral, but bilateral and multilateral fistulas may occur. In multilateral CPFs, the value of a multidetector computed tomography (MDCT) imaging technique as an adjuvant to coronary angiography (CAG) is eminent. The purpose of this study was to describe the clinical presentation, diagnostic modalities, and management of coincidentally detected congenital CPFs.

HYPOTHESIS

Unilateral and multilateral coronary-pulmonary fistulas are increasingly detected due to the wide speard application of multidetector computed tomography which might be a supplementary or replacing to conventional coronary angiography.

METHODS

We evaluated 14 adult patients with congenital coronary artery fistulas (CAFs) who were identified from several Dutch cardiology departments.

RESULTS

Fourteen adult patients (5 female and 9 male), with a mean age of 57.5 years (range, 24-80 years) had the following abnormal findings: audible systolic cardiac murmur (n = 4), chronic atrial fibrillation (n = 2), nonsustained ventricular tachycardia (n = 1), and cardiomegaly on chest x-ray (n = 2). Echocardiography revealed normal findings with trivial valvular abnormalities (n = 9), depressed left ventricle systolic function (n = 3), and severe mitral regurgitation and atrial dilatation (n = 2). The findings in the rest of the patients were unremarkable. CAG and MDCT were used as a diagnostic imaging techniques either alone (CAG, n = 6; MDCT, n = 1) or in combination (n = 7). Single modality and multimodality diagnostic methods revealed 22 fistulas including CPFs (n = 15), coronary cameral fistulas terminating into the right (n = 2) and the left atrium (n = 1), and systemic-pulmonary fistulas (n = 4). Of all of the fistulas, 10 were unilateral, 6 were bilateral, and 6 was hexalateral. (13) N-ammonia positron emission tomography-computed tomography was performed in 3 patients revealing decreased myocardial perfusion reserve.

CONCLUSIONS

CAG remains the gold standard for detection of CPFs. An adjuvant technique using MDCT provides full anatomical details of the fistulas.

Surgical repair of coronary artery fistula combined with coronary artery ectasia in adults

OBJECTIVES

Coronary artery fistula (CAF) is rare in patients undergoing coronary angiography. Coronary artery ectasia (CAE) is found in 1.2% to 4.9% of patients at autopsy or during angiographic studies. CAF combined with CAE is a extremely rare clinical condition. This study aimed to summarize a treatment strategy for this complex disorder.

METHODS

Ten consecutive patients who underwent surgical repair of CAF combined with CAE between 2000 and 2012 are reported. The main outcome measure was death. Secondary outcome measures included surgical technique, the extracorporeal circulation time, intubation duration, the intensive care unit stay period and discharge period.

RESULTS

The mean extracorporeal circulation period was 103.8 W 25.7 minutes. The mean intubation duration was 10.5 W 3.2 hours. The mean intensive care unit stay period was 2.0 W 0.8 days and the mean discharge period was 11.4 W 2.6 days two patients were lost to follow-up. The other eight patients were asymptomatic and there were no deaths during the follow-up period.

CONCLUSIONS

Surgical repair for CAF combined with CAE is effective with satisfactory results in adults.

Iatrogenic Aortocoronary Arteriovenous Fistula following Coronary Artery Bypass Surgery: A Case Report and Complete Review of the Literature

The case of a patient who presented with angina following a coronary artery bypass (CABG) operation during which the left internal mammary artery was inadvertently anastomosed to a cardiac vein is presented. The literature concerning previously reported cases of aortocoronary arteriovenous fistulas (ACAVF) due to inadvertent grafting of a coronary vein is reviewed and the significance of this complication is discussed. ACAVF due to inadvertent grafting of a coronary vein is a rare complication of CABG and may be a more common cause of graft failure than has previously been recognized. Distortion of cardiac anatomy, the presence of epicardial fat, and an intramyocardial course of the artery intended for grafting are predisposing factors. Some patients present with angina pectoris and heart failure whereas others have no symptoms. The diagnostic test of choice is coronary angiography. Cardiac MRI and CT have a limited role due to the smaller size and the more clearly defined course of these fistulas. Asymptomatic patients are simply observed since spontaneous closure of these fistulas is reported. Symptomatic patients can be treated with combined medical management and percutaneous methods.

Applying preoperative multidetector computed tomography to bilateral coronary artery fistulas

Coronary artery fistula arising from both the right coronary artery and the circumflex coronary artery is rare. A 28-year-old woman with non-insulin-dependent diabetes mellitus and end-stage renal disease who was on regular hemodialysis complained of recent progressive exertional dyspnea. Congestive heart failure was diagnosed during work-up for simultaneous kidney and pancreas transplantation. Bilateral coronary fistulas draining into the coronary sinus were found by coronary angiography and further characterized by multidetector computed tomography followed by 3D reconstruction preoperatively. The operation was performed smoothly without heart arrest.

Congenital solitary coronary artery fistulas characterized by their drainage sites

Last centuries have witnessed tremendous sophistication and progress in the detection, diagnosis and treatment of coronary artery fistulas (CAFs). In many countries, CAFs were reported to be visualized and treated using several imaging techniques and different management strategies. Reports from nearly all continents of the globe have contributed to the description of CAFs, not only in Asia and Europe but also throughout North and Latin America. However, these reports have to be cautiously analyzed as many of them were published as a case report and careful interpretation is warranted due to possible publication bias. A literature search was performed using PubMed search interface to select papers dealing with congenital CAFs in adult population between 2000-2009. A total of 233 subjects were collected, and analysed according to their drainage site and treatment modality. They were divided into two subgroups: percutaneous transluminal embolization group (PTE group, n = 122) and surgical ligation group (SL group, n = 111). In the SL group, atherosclerotic coronary artery disease (19%) and associated congenital lesions (23%) were more prevalent compared with the PTE group (9% and 8%), respectively. Infective endocarditis was more frequently seen in the SL group besides syncope, congestive heart failure and hemopericardium. In both groups multimodality diagnostic workup composed of several non-invasive and invasive imaging techniques for fistula visualization were performed and drainage sites into the different cardiac chambers and intrathoracic great vessels were similarly distributed in the two groups.

An aneurysmal left circumflex artery-to-right atrium fistula in a patient with ischemic symptoms: accurate diagnosis with dual-source CT angiography

In this report, we present a 55-year-old female patient with a left circumflex artery-to-right atrial fistula associated with a huge saccular aneurysm. She had undergone conventional angiography due to ischemic symptoms. In conventional angiography, a very dilated and tortuous vessel originating from the circumflex artery and continuous with a huge saccular aneurysm was visualized but the drainage site could not be demonstrated. With dual-source CT coronary angiography, the exact anatomy of this fistula was demonstrated and surgery was planned.