Coronary steal: how many thieves are out there?

Influence of Left Subclavian Artery Stent Graft Geometry on Blood Hemodynamics in Thoracic Endovascular Aortic Repair

The objective of this research is to analyze the hemodynamic differences in five configurations of left subclavian artery (LSA) stent grafts after LSA endovascular reconstruction in thoracic endovascular aortic repair (TEVAR). For numerical simulation, one three-dimensional thoracic aortic geometry model with an LSA stent graft retrograde curved orientation was reconstructed from post-TEVAR computed tomography angiography (CTA) images, and four potential LSA graft configurations were modified and reconstructed: three straight (0, 2, and 10 mm aortic extension) and one anterograde configuration. The blood perfusion of the LSA, flow field, and hemodynamic wall parameters were analyzed. The vortex evolution process was visualized by the Liutex method which enables accurate extraction of the pure rigid rotational motion of fluid and is highly suitable for identifying the vortex structure of blood flow near the vessel wall. The average flow in the retrograde configuration decreased by 11.2% compared to that in the basic configuration. When the LSA stent graft extends in the aortic lumen, flow separation is observed, and vortex structures begin to form at the proximal inferior arterial geometry and the wall of the extension in late systole. A greater extension length and inflow angle upstream resulted in a greater oscillatory shear index (OSI) and relative residence time (RRT) on the nearby wall of the posterior flow field of the extension. Shorter intra-aortic extension length (<10 mm) and smaller LSA stent graft inflow angle (<120 deg) may be recommended in TEVAR, considering LSA perfusion and minimized flow field disturbance.

Correlation between carotid and/or subclavian atherosclerotic plaque and coronary atherosclerotic disease

BACKGROUND AND AIM

The present study aimed to analyze the correlation between carotid atherosclerotic plaque (CAP) and/or subclavian atherosclerotic plaque (SAP) and coronary atherosclerosis disease (CASD).

METHODS

A total of 1343 patients hospitalized for chest pain or tightness due to coronary atherosclerotic disease and underwent initial coronary angiography (CAG) were evaluated by color Doppler flow imaging (CDFI) for CAP and SAP. The patients were divided into four groups: non-CAP & non-SAP, only-SAP, only-CAP, or CAP & SAP. Finally, 1,242 patients were included in this study.

RESULTS

The incidence of CASD and main coronary artery disease in the CAP & SAP group was higher than that in the CAP-only group. Moreover, the detection rate of three-vessel disease (3-VD) in the CAP & SAP group was significantly higher than that in the CAP group (p < 0.05). The incidence of main coronary artery branch lesions in patients with CAP & SAP was approximately 1.5 times higher than in those with only CAP. Male gender, hypertension, and diabetes were independent risk factors for main coronary artery branch lesions. If the patient had CAP & SAP lesions and more than three cardiovascular disease risk factors, coronary artery main artery disease incidence was about 81.7% CONCLUSION: Based on the CDFI screening and combined with cardiovascular disease risk factors, the combined evaluation of CAP and SAP showed higher CASD prediction values than the CAP group alone. Early detection of coronary atherosclerotic stenosis and timely clinical intervention is expected to reduce the incidence of ischemic heart disease events caused by coronary atherosclerotic stenosis.

A coronary coronary-to-coronary fistula around the main pulmonary artery

Coronary-to-coronary fistulas are rare anomalies, often detected incidentally. These fistulas may involve complex vascular connections around major cardiac structures, such as the pulmonary artery. Functional assessments help determine clinical significance, with management typically involving observation for asymptomatic patients, while symptomatic cases may require intervention to prevent complications.

Complicated atrial myxoma with coro-cameral fistula arising from its feeding branch: a case report

A 56-year-old man with a 5-year history of paroxysmal palpitations, which have worsened over the past year, was diagnosed with atrial fibrillation. During evaluation, transesophageal echocardiography revealed a left atrium (LA) tumoral mass attached to the atrial septal fossa ovale, with intra-tumoral blood flow and blood stream draining from the mass. Both coronary computed tomography angiography and coronary angiography demonstrated a coro-cameral fistula connection between the left circumflex artery (LCX) branch and the LA. In addition, they showed feeding arteries of the mass arising from the LCX. The patient underwent surgical resection of the LA mass and repair of the coronary artery fistula. Intraoperative exploration revealed a 1.7 cm × 1.0 cm jelly-like, brittle LA mass and confirmed a rupture of the supplying artery, leading to a coronary artery-left atrial fistula. Surgical ligation was executed to ensure complete sealing of the supplying coronary branch within the atrial septum. Histopathological examination confirmed the diagnosis of left atrial myxoma. The 6-month follow-up indicated no recurrence of the myxoma and restoration of sinus rhythm after radiofrequency ablation. In the literature, cases of a left circumflex artery branch-left atrial fistula due to rupture of the artery supplying a left atrial myxoma are rare.

Embolization of a Large Right-Coronary-Artery-to-Left-Atrium Fistula in a Three-Year-Old Child: A Case Report

OBJECTIVES

Coronary artery fistulas (CAFs) are rare congenital anomalies with an occurrence rate of 0.002-0.3%. The right coronary artery (RCA) is reportedly the most common site of origin of CAFs, but fistulas draining to the left atrium (LA) are rare. We presented a three-year-old boy with a symptomatic congenital RCA-to-LA fistula, which was successfully percutaneously occluded with an Amplatzer vascular plug 4 (AVP4).

CASE REPORT

The diagnosis was made by echocardiography when he was two months old. During the follow-up period of 2 years, a progressive dilatation of the RCA and enlargement of the left ventricle was detected, so treatment for congestive heart failure was initiated. At the age of three, the patient presented with a history of occasional mild central chest pain and discomfort and mild dyspnea on exertion. On a 24 h ECG Holter monitor, the depression of ST segments was registered. CT angiography highlighted a large type B RCA fistula to the LA, which extended along the atrioventricular sulcus. The proximal RCA diameter was 7 mm. The fistula was tortuous, with segmental narrowing and three curves. Cardiac catheterization was performed across the right femoral artery on the three-year-old boy (body weight: 13 kg). Across the 4F Judkins right guiding catheter, an AVP4 of 5 mm was placed in the distal part of the CAF connected with the delivery cable. After 15 min, ECG changes were not registered, so the device was released. Immediate post-deployment angiography demonstrated complete CAF occlusion, with satisfying flow in the distal coronary artery. The patient was discharged after four days. In the short-term follow-up period, the boy was symptom-free.

CONCLUSIONS

In our experience, given the existence of the left-to-left shunt and the more pronounced exercise-induced coronary steal phenomenon that occurs in medium-sized and large CAFs, occlusion is necessary to prevent the further progression of clinical signs and symptoms.

The functional impact on donor vessel following transcatheter closure of coronary artery fistulas-a retrospective study using QFR analysis

Background

The impact of transcatheter closure of coronary artery fistula (CAF) and residual shunt after occlusion on improving blood flow in the donor vessel remains uncertain.

Objectives

To evaluate the functional impact on the donor vessel following CAFs closure using QFR (Quantitative Flow Ratio) analysis.

Methods

A total of 46 patients with 48 CAFs who underwent transcatheter closure at Shanghai Chest Hospital and Shuguang Hospital between March 2015 and August 2023 were included in the review. The clinical, angiographic details, and QFR data were subjected to analysis. The size of the fistulae was defined according to the ratio between the diameters of the fistulae and the largest diameter of the coronary vessel not feeding the coronary fistula.

Results

Among 48 CAFs, the average diameter of the fistulae ostium was 3.19 ± 1.04 mm, while the mean diameter of the donor vessel segment following fistulae was 3.45 ± 1.01 mm. The mean QFR value of the donor vessels with medium CAFs was found to be significantly lower than those with small CAFs (0.93 ± 0.10 vs. 0.98 ± 0.03; p < 0.05). Furthermore, the mean QFR value of donor vessels with medium CAFs was observed to be significantly improved after occlusion (0.99 ± 0.01 vs. 0.93 ± 0.10; p = 0.01). However, there was no statistical difference in the mean QFR value of donor vessels with small CAFs before and after occlusion (0.98 ± 0.03 vs. 0.98 ± 0.02; p > 0.05). Moreover, the changes in QFR were more pronounced in donor vessels with medium CAFs compared to those with small CAFs after occlusion (0.06 ± 0.10 vs. 0.005 ± 0.012; p = 0.01). There is no statistical difference in the mean QFR variation and QFR variation rate between donor vessels with CAFs that occurred residual shunt and those without residual shunt after occlusion (p > 0.05).

Conclusions

The presence of medium CAFs has a significant impact on the blood flow of the donor vessel, as compared to small CAFs, and may benefit from occlusion. A small residual shunt has no significant impact on the effectiveness of CAFs occlusion in enhancing donor blood flow.

Anomalous Arising of Right Coronary Artery from the Pulmonary Artery

Coronary artery anomalies are seen in less than 1% of the general population and in 1.6% of cardiac catheterization cases. The anomalous origin of the coronary artery from the pulmonary artery is one of four groups of coronary artery origin anomalies. The incidence of anomalous origin of the right coronary artery from the pulmonary artery is 1 in 500,000 and was first described in 1882 by John Brook. This case report reports on a 67-year-old man with a diagnosis of asymptomatic anomalous origin of the right coronary artery from the pulmonary artery. The patient underwent surgery of the aortic valve because of valve stenosis. A concomitant surgical procedure included repositioning of the right coronary artery origin to the aortic root sinus. The patient was discharged on the 12th postoperative day, in good condition. Anomalous origin of the right coronary artery from the pulmonary artery is commonly asymptomatic, and surgery is required only if myocardial ischemia is presented.

Exertional angina after cardiac bypass surgery successfully solved by endovascular occlusion of unligated lateral costal artery

The internal mammary artery has become the primary conduit for the surgical revascularisation of the left anterior descending artery. Large side branches of internal mammary artery are typically ligated during cardiac surgery to avoid a potential coronary steal phenomenon. However, ligation of side branches can be unsuccessful due to the technically difficult surgical exploration of internal mammary artery branches. In this article, we present a case of a man who suffered from exertion angina pectoris despite successful surgical revascularisation of occluded left anterior descending artery by the internal mammary artery bypass. The coronary steal syndrome caused by the mighty side branch of internal mammary artery, that is, lateral costal artery was concluded as the reason of exertional angina. The endovascular procedure was performed and the lateral costal artery was successfully occluded using vascular plug. The occlusion of lateral costal artery has led to a complete disappearance of the exertional angina.