Surgical Treatment of Circumflex Coronary Aneurysm with Fistulous Connection to Coronary Sinus Associated with Persistent Left Superior Vena Cava

Acute myocardial infarction due to giant coronary artery aneurysm and arteriovenous fistula: a challenging case report and review of the literature

BACKGROUND

A coronary artery aneurysm (CAA) is an abnormal dilation of a coronary artery segment often accompanied by coronary artery fistula (CAF), leading to communication between a coronary artery and a cardiac chamber or a part of the coronary venous system. Both CAAs and CAFs can present with symptoms and signs of myocardial ischemia and infarction.

CASE PRESENTATION

We describe the case of a 46-year-old woman with non-ST-elevation myocardial infarction (NSTEMI) caused by a "giant" CAA. Various imaging modalities revealed a thrombus-containing aneurysm located at the right-posterior cardiac border, with established arteriovenous communication with the distal part of left circumflex artery (LCx). After initial treatment with dual antiplatelet therapy, a relapse of pain was reported along with a new increase in troponin levels, electrocardiographic abnormalities, reduced left ventricular ejection fraction (LVEF) and thrombus enlargement. Surgical excision of the aneurysm was favored, revealing its true size of 6 cm in diameter. Τhe aneurysm was excised without complications. The patient remained asymptomatic during follow-up.

CONCLUSIONS

Management of rare entities such as "giant" CAAs and CAFs can be challenging. Cases such as this can serve as precedents to facilitate treatment plans and develop consistent recommendations, emphasizing the importance of personalized strategies for future patients.

Transcatheter arterial embolization of the subclavian and axillary artery branches for hemorrhage control

OBJECTIVE

To evaluate the effectiveness and safety of transcatheter arterial embolization (TAE) of the branches of the subclavian and axillary arteries for hemorrhage control.

METHODS

Between January 2015 and June 2022, 35 TAE procedures were performed for hemorrhage from the branches of the subclavian and axillary arteries in 34 patients (22 men, 12 women; 1 male underwent TAE twice; mean age = 76 years). Pre-TAE CT showed hematomas in the chest (n = 25) and abdominal walls (n = 3), shoulder (n = 2), and lower neck (n = 2). CT showed hemothorax in eight cases. Angiographic findings, embolization technique, and technical and clinical success of TAE were retrospectively assessed in all cases.

RESULTS

TAE was performed by transfemoral (n = 16), transradial (n = 12), and transbrachial (n = 7) approaches. Angiography revealed contrast media extravasation or pseudoaneurysms in 32 cases (91.4%). The most commonly embolized arteries were the internal thoracic (n = 12), lateral thoracic (n = 6), and thoracoacromial (n = 6) arteries. Technical and clinical success rates were 100 and 85.7%, respectively. A complication (skin necrosis after injection of the liquid embolic agent) developed in only one patient (2.9%) and was conservatively managed.

CONCLUSION

TAE is an effective and safe treatment for hemorrhage from the branches of the subclavian and axillary arteries.

ADVANCES IN KNOWLEDGE

Transfemoral approach has been used for TAE of the branches of the subclavian and axillary artery. Transradial and transbrachial approaches can also be considered.

A rare case of giant left circumflex coronary artery fistula to coronary sinus in patient with persistent left superior vena cava and bicuspid aortic valve

A 61-year-old male presented with symptoms of decompensated heart failure and cardiogenic shock. Transthoracic and transesophageal echocardiography showed severely impaired left ventricular (LV) systolic function (LVEF of 20-25%), bicuspid aortic valve with moderate aortic insufficiency and no significant stenosis, dilated coronary sinus and a tortuous vascular structure in the left-sided atrioventricular groove. Cardiac computed tomography confirmed the diagnosis of persistent left superior vena cava and a giant coronary artery fistula to the coronary sinus. Cardiac magnetic resonance illustrated non-specific late gadolinium enhancement in the mid-wall of the septum. The patient was treated medically and with cardiac re-synchronization therapy.

Coronary Arteriovenous Fistula Draining Into Persistent Left Superior Vena Cava

A 75-year-old woman was referred to our hospital for dyspnea and edema of the lower limbs. Computed tomography angiography revealed a dilated left coronary artery from the left main trunk to the left circumflex branch and a dilated fistula originating from the left circumflex branch and draining into the persistent left superior vena cava. Physical examination revealed pulmonary hypertension and congestive heart failure. We performed closure of the fistula and left main coronary artery orifice and coronary artery bypass grafting. Postoperative computed tomography angiography showed patency of all grafts and progression of thrombosis in the dilated abnormal vessels.

Novel visualised three-dimensional images are useful for treating coronary artery fistulas in infants

Here we report an infant with coronary artery fistulas. To clearly visualise the fistulas and surrounding materials, we utilised three-dimensional computed tomography, and the images were transferred as novel visualised three-dimensional images using a reconstruction technique. With the images, we could repair the fistulas accurately. We believe that these images are useful for repairing coronary artery fistulas in infants.

Giant coronary artery fistula

Giant coronary artery fistula is rare. We describe the diagnostic work-up and surgical management of a 55-year-old woman who presented with congestive heart failure caused by a giant coronary artery fistula from the left circumflex artery to the coronary sinus.

A rare combination of the left circumflex coronary artery fistula connecting a dilated coronary sinus with persistent left superior vena cava and multiple arteriovenous fistulae

Coronary artery fistula (CAF) is an abnormal communication between an epicardial coronary artery and a cardiac chamber, major vessel or other vascular structures. This report presents a rare case of CAF in which a dilated left main trunk and proximal circumflex coronary artery are connected to a dilated coronary sinus. There were also two other fistulae and persistent left superior vena cava. The coronary fistula was managed conservatively.

A case of giant coronary artery aneurysm with fistulous connection to the pulmonary artery: a case report and review of the literature

Giant coronary artery aneurysm is a rare condition with a reported prevalence of 0.02%. Herein, we report the case of a 79-year-old woman with a giant coronary aneurysm arising from a branch of the left anterior descending coronary artery that had a fistulous connection to the pulmonary artery. The aneurysm was removed and inflow and outflow arteries were closed surgically. Histology showed prominent mucinous degeneration and infiltration of inflammatory cells in the medial layer. After successful surgery, the patient was discharged uneventfully.