Coronary artery fistulas: CT findings

Prevalence of anomalies and variants of coronary arteries: A single center study by coronary CT angiography

PURPOSE

It has been demonstrated that the coronary artery anomalies (CAAs) are generally asymptomatic. However, some cases can cause severe life threatening events. As coronary computed tomography angiography (CCTA) has emerged as a non-invasive alternative to invasive coronary angiography for the evaluation of coronary anatomy, the prevalence of CAAs in CCTA may more closely reflect the true prevalence in the general population. So we aimed to review and determine the prevalence of CAAs and variants retrospectively in patients who underwent CCTA at our center.

METHODS

Reports of 1802 patients who underwent CCTA at the radiology department of our university hospital were traced for CAAs. At least two independent investigators reviewed the images, which were selected for further assessment prior to final classification.

RESULTS

One hundred and fifty two anomalies in 152 patients (8.44 %) were encountered. Origin of any coronary artery from the pulmonary trunk in 1 (0.06 %), origin of LMCA from right sinus in 1 (0.06 %), origin of right coronary artery (RCA) from left sinus in 5 (0.28 %), origin of left anterior descending artery (LAD) from right sinus in 2 (0.11 %), origin of circumflex branch (RCx) of LMCA from right sinus in 6 (0.33 %), origin of RCx from RCA in 4 (0.22 %), origin of any coronary artery from the ascending aorta in 2 (0.11 %), split RCA in 5 (0.28 %), RCx and left marginal artery from the first diagonal artery in 1 (0.06 %), myocardial bridging in 123 (6.83 %) and fistula in 2 (0.11 %) were detected as CAAs.

CONCLUSION

The prevalence of CAAs observed in this study was similar to the literature. CCTA can clearly visualize the anomalous origin, course and termination of the coronary artery.

Transcatheter closure of multiple coronary artery fistulas: a coronary computed tomography angiography-based anatomic classification

INTRODUCTION AND OBJECTIVES

This study aimed to retrospectively analyze the anatomical characteristics and classification of multiple coronary artery fistulas (MCAFs), and to compare the outcomes of transcatheter closure between MCAFs and single fistulas.

METHODS

All patients who underwent attempts at transcatheter closure of coronary artery fistulas (CAFs) at Fuwai Hospital from 2010 to 2023 were retrospectively reviewed. Patients were categorized into single fistula and MCAFs groups, and anatomical characteristics and transcatheter closure outcomes were compared between the 2 groups.

RESULTS

This retrospective study included 146 patients who underwent attempted transcatheter closure of CAFs, with a 14.38% failure rate. Among the 146 patients with CAFs, 32.19% were identified as having MCAFs, with types I, II, and III constituting 40.43%, 42.55%, and 17.02%, respectively. Unlike single fistulas, which predominantly originated from the right coronary artery and terminated in the left ventricle, MCAFs mainly had simultaneous origins from the right coronary artery and left anterior descending artery (29.79%), and predominantly drained into the pulmonary artery (70.21%), with a notable prevalence of plexus-like morphology (38.3% vs 2.02%, P<.001). The success rate of transcatheter closure was significantly lower for multiple fistulas compared with single fistula (64.29% vs 84.34%, P=.011). Multivariate regression analysis indicated that the risk of closure failure for MCAFs was 2.64 times that of single fistulas.

CONCLUSIONS

MCAFs are common among CAFs and can be classified into 3 types based on the number and location of their origins and terminations. The risk of failure of transcatheter closure is significantly higher in MCAFs than in single fistulas.

Strategic approach to embolization of coronary to pulmonary artery fistulas: a technical note

BackgroundCongenital coronary artery to pulmonary artery fistulas (CPAFs) are extremely rare congenital vascular malformations.PurposeTo give a practical approach and consider technical challenges and pitfalls for endovascular embolization of CPAF.Material and MethodsAnatomic, technical, and pathophysiologic considerations are given and demonstrated for antegrade and retrograde endovascular embolization of CPAF.ResultsAntegrade embolization is easier to perform, saves radiation exposure, and is recommended especially in younger patients. In case of a single dominant feeder, antegrade embolization of this feeder might sufficiently treat the CPAF. Retrograde embolization from the pulmonary orifice is technically more challenging but leads to a complete and definite closure of the fistula in one single step.ConclusionPatient age and fistula configuration must be taken into consideration for appropriate treatment approach in CPAF. Prerequisite for successful embolization of CPAF is profound clinical and interventional experience, why we highly recommend to both plan and carry out embolization of CPAF as interdisciplinary procedure.

Pediatric coronary cameral fistula in a structurally normal heart: a case report and review of the literature

INTRODUCTION

Coronary cameral fistulas (CCFs) are rare congenital anomalies characterized by abnormal connections between a coronary artery and one of the cardiac chambers. These abnormal connections can lead to significant clinical implications, including heart failure and myocardial ischemia, necessitating timely diagnosis and intervention.

CASE PRESENTATION

A 5-year-old Iranian boy was brought to the emergency room at Heart Hospital Center complaining of chest pain and dyspnea on exertion. He had experienced similar episodes over the past 4 months, which had not been evaluated. Physical examination revealed stable vital signs and no remarkable findings. Transthoracic echocardiography demonstrated a dilated left coronary artery with a large aneurysm and a small orifice to the right ventricular body. The left ventricular ejection fraction was 55%. Cardiac computed tomography angiography confirmed the diagnosis. Cardiac angiography showed a dilated left coronary artery and a coronary cameral fistula to the right ventricular . The aneurysm was successfully occluded using two Amplatzer™ devices.

CONCLUSION

This case underscores the critical role of multimodal imaging in diagnosing and managing coronary cameral fistulae. Early detection and appropriate intervention are paramount in preventing the progression of symptoms and potential complications such as heart failure and myocardial ischemia. The successful closure with Amplatzer™ devices highlights the efficacy of minimally invasive techniques in treating complex cardiovascular anomalies. Regular follow-up and careful monitoring are essential to ensure long-term success and to manage any potential recurrences.

CLINICAL KEY MESSAGE

Timely identification and management of coronary cameral fistulae are crucial to prevent complications. Advances in imaging techniques and minimally invasive treatments, such as transcatheter closure, offer effective solutions. A multidisciplinary approach and regular follow-up are essential for comprehensive care and successful long-term management.

Coronary Artery Anomalies: A Computed Tomography Angiography Pictorial Review

Coronary arteries have a wide range of anatomical variability, and their spectrum ranges from asymptomatic cases to those predisposed to hemodynamic compromise or even sudden cardiac death. This paper aims to review the classification of coronary artery anomalies (CAAs) and illustrate their imaging characteristics by highlighting the important role of CT coronary angiography. Some of the coronary anomalies usually met in current practice are the high origin coronary artery, multiple ostia, aberrant origin from the opposite/non-coronary Valsalva sinus, single coronary artery, ALCAPA syndrome, duplications of the left anterior descending artery, coronary fistulas, and extracardiac terminations. CT coronary angiography is a non-invasive diagnostic modality for CAAs. The complex anatomy of these anomalies can be accurately described by employing 3D reconstructions and post-processing techniques. Knowledge of the imaging characteristics and potential functional impact of these anomalies is essential for accurate diagnosis and therapeutic planning of patients.

Spontaneous thrombosis of a giant aneurysm complicated with the coronary-to-pulmonary artery fistula: a case report

Background

A coronary-to-pulmonary artery fistula (CPAF) with a giant aneurysm is a rare clinical occurrence. The rupture of an aneurysm leads to a fatal outcome, thus prompting the incorporation of prophylactic measures, which have encompassed surgical resections or endovascular embolization procedures. The indications for these treatment strategies are controversial, and little has been elucidated regarding the salient characteristics underpinning the selection of a therapeutic strategy. We report a case of a giant aneurysm associated with CPAFs that was thrombosed before interventional treatment.

Case summary

A 43-year-old woman, who had previously undergone a right adrenalectomy for primary aldosteronism, was referred for an abnormal heart silhouette on a chest X-ray, which had not been seen three years earlier. Contrast-enhanced computed tomography and coronary angiography (CAG) revealed a giant aneurysm on the anterior aspect of the heart associated with two CPAFs. Because of the risk of rupture of the aneurysm, surgical resection was recommended; however, the patient requested endovascular therapy. On the day of intervention, CAG showed spontaneous occlusion of the feeding vessel to the aneurysm, and the aneurysm showed minimal contrast agent, suggesting spontaneous thrombosis. Because of possible recanalization of the aneurysm, coil embolization was performed, without complications. The patient remained asymptomatic, and the aneurysm was completely embolized at the one-year follow-up.

Discussion

The case shows that minimally invasive endovascular treatment is feasible instead of surgical resection for giant aneurysms associated with CPAFs, depending on their morphological characteristics. This perspective may offer novel insights into treatment strategies for CPAF.

Coronary Artery Fistula: A Diagnostic Dilemma

Coronary artery fistula (CAF), although one of the rare coronary anomalies, is becoming increasingly more detectable in the recent years due to advancements in cardiac diagnostic imaging. Its long-term prognostic implications and importance for the cardiovascular system remain a dilemma for cardiologists and patients. Based on a variety of haemodynamic symptoms and complications, cardiologists must be aware of the characteristics of CAF and the diagnostic importance of multi-slice CT in evaluation, pre-procedural management and follow-up. Both surgical and percutaneous options are available for symptomatic patients or those with complications, while management of asymptomatic CAF remains a viable alternative.

Cinematic Rendering of Complex Coronary Artery Left Atrial Fistula

Supplemental material is available for this article.

Giant left coronary artery diagonal branch left ventricular fistula: A case report and review of literature

A 37-year-old Chinese man was admitted to the department of cardiology of the First Hospital of Jilin University for intermittent palpitation for 9 months, aggravating with chest pain for 3 days. After several examinations, he was diagnosed with giant left ventricular fistula of the diagonal branch of the left coronary artery. After routine treatment, which included improving circulation and administration of dual antiplatelet as well as hypolipidemic drugs among others, the patient’s symptoms did not improve. The fistula was too big for transcatheter occlusion to be performed. A multi-disciplinary suggestion was that the patient be subjected to “surgical closure treatment”; however, for personal reasons, he refused the operation. After discharge, oral beta-blockers were prescribed for the patient. Incidences of congenital coronary arterial fistula in congenital cardiovascular disease are rare, and incidences of the giant fistula being located in the left heart system are even rarer. We report an adult male with a giant left anterior descending diagonal coronary artery left ventricular fistula and show various accessory examination results. Non-invasive ultrasonic cardiography was the first diagnostic option for the disease and pre-admission evaluation. Auxiliary diagnosis and exclusion value of cardiovascular magnetic resonance (CMR) were revealed for the first time. Invasive coronary angiography (ICA) was demonstrated to be the gold standard method again and it was also found that computed tomography angiography (CTA) might be used instead of ICA for determining the exact relationships among anatomic structures. Furthermore, we performed a literature review on the diagnosis and treatment of patients with this condition.

Left Anterior Descending Artery to Pulmonary Artery Fistula: A Case Report

This case describes a 59-year-old patient who initially presented with symptoms consistent with stable angina and a subsequent diagnosis of non-ST elevation myocardial infarction with further conversion to an ST-elevation myocardial infarction. A left cardiac catheterization was scheduled to evaluate the patient’s acute coronary syndrome. He later developed worsening chest pain and a repeat electrocardiogram (ECG) showed ST elevations in anterolateral leads. The patient was emergently transported to the cardiac catheterization lab. The coronary angiogram revealed a proximal left anterior descending artery (LAD) lesion. During the catheterization, abnormal communication between the LAD and the pulmonary artery was discovered and the patient was diagnosed with a coronary artery fistula. This case presents a unique scenario for an ST-elevation myocardial infarction with an incidental diagnosis of a coronary artery fistula. 

A Phenotype and Genotype Case Report of a Neonate With Congenital Bilateral Coronary Artery Fistulas and Multiple Collateral Arteries

We report a unique case of an 18-day-old girl with three coronary artery fistulas to the right atrium and right ventricle, respectively: three collateral arteries arising from the descending aorta and one from the right subclavian artery draining through a sac to the top of the right atrium, patent ductus arteriosus, and atrial septal defect. She presented symptoms of acute congestive heart failure. Cardiac catheterization and surgical interventions were performed to repair the defects. The patient recovered uneventfully and grew up well at 3 years of follow-up. Whole-genome sequencing (WES) in the patient, compared to her parents, showed 17 variants within 11 genes. Among these, only compound heterozygous mutation, c.T470G (p.L157R) and c.A1622G (p.D541G), in the DRC1 gene have been reportedly related to congenital heart disease and are the most likely causative in our patient.

Coronary to pulmonary artery fistula associated with significant coronary atherosclerosis and severe aortic valve stenosis: A Case Report

Coronary artery fistulas are anomalous connections between one or two coronary arteries with either a cardiac chamber or any major blood vessels (coronary sinus, superior vena cava, pulmonary veins and pulmonary artery). It is rarely reported, occurring only in 0.1%-0.2% of patients who undergo coronary angiography. We report a very rare case where myocardial ischaemia may have resulted from the presence of coronary artery fistula, significant coronary artery stenosis and severe aortic valve stenosis. Transthoracic echocardiography showed severe aortic stenosis, while coronary angiography showed a tortuous coronary artery fistula originating from the proximal left anterior descending artery, with a single opening in the main pulmonary artery. Angiography also showed significant stenosis in the middle of the left anterior descending artery. Coronary artery fistula with concomitant significant coronary atherosclerosis and severe aortic stenosis requires optimal therapeutic planning.

CTA analysis of 482 cases of coronary artery fistula: A large-scale imaging study

OBJECTIVE

The prevalence of coronary artery fistula (CAF) based on coronary angiography has been reported. However, with the popularity of coronary computerized tomography angiography (CTA), CAFs have been found more and more by chance. The purpose of this study was to determine the prevalence and types of CAFs detected by coronary CTA, and to explore the differences in the size of fistulas, the number of complicated aneurysms, and fistulas among different types.

MATERIALS AND METHODS

From January 2016 to December 2020, 96,037 patients underwent coronary CTA in our hospital. The prevalence of CAF was retrospectively evaluated, The origin, course, and drainage site of CAF and coexisting abnormalities were analysed. The conventional treatments and follow-up DSCT images were also evaluated. Analyze the difference between the coronary-pulmonary artery fistula (CPAFs) group (380) and the coronary-cameral fistula (CCF) group (99).

RESULTS

Among 96,037 patients, 482 (0.5%) patients (male 232 and 250 female) had CAF. The types of CAF detected. The pulmonary artery was the most common site of drainage (380/482, 78.8%). Of the 99 CCFs, coronary to the left ventricle is the most common pattern in CCF (34/482, 7.0%). Single origins are more common in CAF (n = 361, 74.9%), multiple origins are more common in CPAFs than in CCF. There were statistically significant differences in the stoma diameter (2.4 ± 1.1 mm vs. 5.4 ± 4.3 mm p < .05), aneurysm complicated (85 cases [85/380] vs. 50 cases [50/99]), the size of aneurysm (8.8 ± 5.7 mm vs. 19.1 ± 11.6 mm, p < .05), and single fistula (261 [261/380] vs. 96 [96/99], p < .05). Most of the 380 CPAFs patients received conservative treatment (350/380, 92.1%), While the 59 CCF patients (59/93, 63.4%) were treated.

CONCLUSIONS

Different from previous reports, the prevalence of CAF in coronary CTA is 0.5%, the incidence of CPAFs is the highest, and the incidence of the left ventricular fistula is higher in CCF. Compared with CPAFs, CCF fistulas were more likely to be associated with a larger diameter of draining, larger aneurysms, single fistula pattern. Coronary artery CTA is a useful and noninvasive imaging method to detect CAF, which is of great significance for the detection of small fistulas and the surgical guidance of complex CAF.

Minimally invasive surgery in the treatment of triple vessel coronary artery disease with coexisting coronary artery fistula

Coexistence of triple vessel coronary artery disease with coronary-pulmonary artery fistula is extremely rare. Minimally invasive cardiac surgery in the treatment of such coexisting disease is so far not reported. This case report emphasizes the feasibility of performing complete revascularization of the coronaries with coronary artery fistula ligation through a minimally invasive anterior thoracotomy, obviating full sternotomy.

Mysterious window: A right coronary artery-left ventricular fistula diagnosed by multiple imaging approaches

Prevalence of primary coronary cameral fistula (CCF) is extremely rare, especially for CCF with its drainage channel into the left ventricle (LV). We describe a 45-year-old male patient with giant aneurysm associated with proximal right coronary artery (RCA), and the distal end of RCA draining into the LV through a fistula, which was discovered by echocardiography. Dual-source computer tomography revealed only the CCF-related giant RCA aneurysm. The drainage site of the fistula and the above coexistent abnormality could not be visualized clearly by coronary artery angiography because of deficient contrast medium filling into the aneurysm. The patient underwent surgical resection of the giant aneurysm and occlusion of the fistula in 2015. Finally, the patient accepted another operation to occlude the residual coronary fistula in 2021.

Congenital Aorto-Cardiac Connections (CACC) Revisited: Introduction of a Novel Anatomic-therapeutic Classification

Abnormal congenital aorto-cardiac communications (CACC) are a heterogeneous constellation of anomalies that provide an abnormal connection between the aorta and other cardiac chambers or structures, including the atria, ventricles, the main pulmonary artery, and the coronary sinus. The current terminology of CACC has significant errors and shortcomings including inconsistent and interchangeable use of terms of fistula and tunnel and lack of an inclusive classification with practical information on therapeutic management. The aims of this study were threefold: firstly, to perform a concise narrative review of congenital pathologic connections between the aortic root and cardiac chambers which include rupture of congenital sinus of Valsalva aneurysm, aorto-left ventricular and less commonly right ventricular tunnels, coronary cameral fistulas, and aorto-atrial communications; secondly, to investigate the differentiating features of the so-called aorta right atrial tunnel (ARAT), with and without coronary artery take-off from the tunnel, and coronary cameral fistula (CCF) by applying a differential diagnostic assistance toolbox to two groups of patients with ARAT and CCF; and lastly, to propose a practical and inclusive anatomic-therapeutic classification for CACCs. The two main cornerstones of the proposed classification are the type of the connector between the aorta and cardiac chamber (hole versus passage) and the nature of the connecting passage ( anatomic versus extra-anatomic). We classified CACCs into three types. Depending on the intramural versus extramural course of the extra-anatomic connecting passage, type 3 is further subdivided into type 3A and type 3B.

Coronary Artery Anomalies

Coronary artery anomalies (CAAs) are a group of congenital conditions characterized by abnormal origin or course of any of the 3 main epicardial coronary arteries. Although CAAs have been identified as a common underlying condition in young athletes with sudden cardiac death, the widespread use of invasive and noninvasive coronary imaging has led to increased recognition of CAAs among adults. CAAS are often discovered as an incidental finding during the diagnostic workup for ischemic heart disease. The clinical correlates and prognostic implication of CAAs remain poorly understood in this context, and guideline-recommended therapeutic choices are supported by a low level of scientific evidence. Several studies have examined whether assessment of CAA-related myocardial ischemia can improve risk stratification in these patients, suggesting that multimodality imaging and functional tests may be key in the management of CAAs. The aim of this review is to outline definitions, classification, and epidemiology of the most relevant CAAs, highlighting recent advances and the potential impact of multimodality evaluation, and to discuss current therapeutic opportunities.

Transcatheter Coil Embolization in 17 Patients with 22 Coronary Artery Fistulas

Coronary artery fistulas are rare anomalies that often become symptomatic with age. They are typically diagnosed incidentally during coronary angiography. The chief nonsurgical treatment is transcatheter coil embolization. We evaluated the outcomes of this procedure in 17 symptomatic patients who had 22 fistulas in total. The 9 men and 8 women (mean age, 52 ± 16.5 yr; range, 27-74 yr) presented at 4 Turkish hospitals from October 2008 through March 2015. Three patients had multiple fistulas. Twelve fistulas originated from the right coronary artery and 10 from the left coronary artery, draining into the pulmonary artery in 18 instances. We evaluated results postprocedurally and after 2 to 5 months, defining angiographic success as a flow better than Thrombolysis in Myocardial Infarction grade 2 in the treated artery. Twenty-one of the 22 procedures immediately produced the targeted flow. We observed 2 minor and no major complications. On follow-up, 3 symptomatic patients underwent successful repeat treatment of one fistula each. We found that transcatheter coil embolization afforded good success rates with few complications in closing coronary artery fistulas. We share our experience to add to the data on treating patients with coronary artery fistulas, and to raise awareness among clinicians.

Congenital Coronary Artery-to-Pulmonary Artery Fistula with Anomalous Origin of Right Coronary Artery from Pulmonary Artery: A Case of "Double Trouble"

Congenital coronary artery fistula is a rare coronary anomaly. Its clinical significance focuses mainly on the mechanism of coronary steal phenomenon. A combination of left main (LM) coronary artery-to-main pulmonary artery (MPA) fistula with anomalous origin of right coronary artery from the pulmonary artery (ARCAPA) was encountered in a 3-month-old infant who presented with tachypnea. Evaluation with echocardiography and CT confirmed the diagnosis. The patient underwent surgical ligation of LM-to-MPA fistula with direct reimplantation of ARCAPA to aortic root. Keywords: Pediatrics, CT, CT-Angiography, Echocardiography © RSNA, 2021.

Coronary Computer Tomography Angiography in 2021-Acquisition Protocols, Tips and Tricks and Heading beyond the Possible

Recent technological advances, together with an increasing body of evidence from randomized trials, have placed coronary computer tomography angiography (CCTA) in the center of the diagnostic workup of patients with coronary artery disease. The method was proven reliable in the diagnosis of relevant coronary artery stenosis. Furthermore, it can identify different stages of the atherosclerotic process, including early atherosclerotic changes of the coronary vessel wall, a quality not met by other non-invasive tests. In addition, newer computational software can measure the hemodynamic relevance (fractional flow reserve) of a certain stenosis. In addition, if required, information related to cardiac and valvular function can be provided with specific protocols. Importantly, recent trials have highlighted the prognostic relevance of CCTA in patients with coronary artery disease, which helped establishing CCTA as the first-line method for the diagnostic work-up of such patients in current guidelines. All this can be gathered in one relatively fast examination with minimal discomfort for the patient and, with newer machines, with very low radiation exposure. Herein, we provide an overview of the current technical aspects, indications, pitfalls, and new horizons with CCTA, providing examples from our own clinical practice.

Fistula from right and left coronary arteries to pulmonary artery: Coronary CT angiography and coronary angiography findings

Coronary artery fistula is an abnormal communication between the coronary artery and either the cardiac chamber or the great vessel. In particular, the coronary-to-pulmonary artery fistula can be supplied by either one or both coronary arteries and drains to the pulmonary trunk. We report a unique case of fistula originating from both coronary arteries and draining into both sinuses of the main pulmonary artery in a 57-year-old female who experienced chronic chest pain and palpitation. Dilated and tortuous fistulas were found in coronary angiography and coronary computed tomography angiography examinations. To aid early diagnosis and clinical management, radiologists should be aware of the characteristic radiologic findings.

A Case of Coronary Cameral Fistula: When and How to Intervene?

Coronary artery fistulas constitute a rare anomaly defined as an abnormal communication between a coronary artery and a great vessel or any cardiac chamber. 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. We present an unusual case of a coronary artery fistula in a middle-aged woman who presented with symptoms of heart failure and abnormal auscultation. Echocardiography and conventional and computed tomography angiography showed that the coronary fistula originated from the left circumflex coronary artery and drained majorly into the right ventricle. Given the complex anatomy of the fistula, we managed it surgically rather than percutaneously. There were no complications early after surgery and at 1 year's follow-up.

A case report of coronary pulmonary artery fistula detected by transthoracic echocardiography in an elderly patient with dyspnea

Coronary pulmonary artery fistula (CPAF) is a rare entity in the population. It may present with multiple clinical settings and in various age ranges. Invasive coronary angiography (ICA), coronary computed tomography angiography (CCTA), and transthoracic echocardiography (TTE) have been reported as diagnostic tools for CPAF. Among them, TTE is rarely capable of identifying CPAF. There is no current treatment guideline as some of the interventional therapies are effective yet controversial. The therapy therefore should be individualized. We report a case of CPAF accidentally detected by TTE in a 93-year-old female who presented with acute respiratory distress on the setting of community-acquired pneumonia, diastolic heart failure, ischemic heart disease, pulmonary hypertension, chronic kidney disease, and hypertension. The patient presented with orthopnea, fever, bilateral pleuritic chest pain, and productive cough with yellowish sputum for 7 days. She had no previous chest trauma or surgical intervention. TTE demonstrated the tortuous enlargement of left coronary artery which drains into the pulmonary arterial trunk right above the pulmonary valve. As the patient was in advanced age with multiple comorbidities; we offered a conservative management including diuretic, oxygen therapy, antibiotic, antiplatelet, and statin. She recovered following a 13-day hospitalization. To our knowledge, this is the oldest case report of suspected congenital CPAF which is particularly detected by TTE.

Complex cardiac vascular malformation: Natures own CABG

True cardiac arteriovenous malformations are rare anomalies that may be acquired or congenital in origin. These anomalies are well demonstrated by Multi Detector Computed Tomography (MDCT) with much higher clarity and anatomic detail than invasive angiography. We report a case of large complex cardiac vascular malformation in 55 year old male involving feeders from systemic (internal mammary artery, right inferior phrenic artery), coronary (left anterior descending), and pulmonary arterial and venous systems using a 64 slice MDCT scanner. Cardiac AV malformations have previously been described using MDCT, but this case is unique in terms of its large size, extensive involvement of systemic, coronary and pulmonary vascular connections, and mild clinical symptomatology. Our case shows that patients with complex coronary malformation may not always require treatment as natures' pathways may work well throughout lifetime.

Innovative method to diagnose coronary Cameral fistula by contrast echocardiography

INTRODUCTION

Coronary artery fistula (CAF) is a rare cardiac anomaly that typically presents as a continuous murmur in an otherwise asymptomatic patient. Occasionally, it can result in congestive heart failure or bacterial endocarditis.

OBJECTIVE

To better delineate the course of coronary artery fistula using an intracoronary injection of SonoVue contrast agent, while performing transthoracic echocardiography.

METHOD AND RESULTS

A referred 46-year-old man, with a history of exertional dyspnea for almost 3 months, was admitted to the hospital with progressive dyspnea and assessed under suspicion of CAF. CAF was seen with a coronary angiogram, but the exact entry point in the left ventricle or left atrial wall could not be determined. CT angiography also failed to establish the drainage site, so CAG (coronary angiography) was repeated with the SonoVue contrast agent injected into LM (Left main) while using a Siemens echocardiography machine. Multiple views were obtained during the injection and revealed unusual flow in the left ventricle just below the PML (posterior mitral leaflet) and passing through the fistula to LV.

CONCLUSION

Contrast-enhanced echocardiography by direct intracoronary injection of SonoVue contrast agent is safe and can aid in the delineation of fistula drainage.

Anomalies of the Coronary Sinus and Its Tributaries: Evaluation on Multidetector Computed Tomography Angiography

Imaging of the coronary sinus and its tributaries has gained increasing significance consequent to the development of an array of electrophysiological and interventional procedures using the cardiac venous system, including ablation for arrhythmias, left ventricular pacing, and in the administration of retrograde cardioplegia. Knowledge of the normal anatomy and the possible anomalies and their clinical significance is imperative to circumvent possible complications. A number of coronary sinus (CS) anomalies, both symptomatic and asymptomatic, have been observed with the widespread use of noninvasive cross-sectional imaging for the imaging of the heart. However, it should be kept in mind that even clinically occult lesions of the CS can cause disastrous complications in specific interventions. Hence, a thorough knowledge of the expected anatomy and the possible anomalies involving the CS along with their clinical significance is imperative for the reporting radiologists and the concerned physicians. In this review, we briefly describe the relevant anatomy and embryology and describe the gamut of anomalies pertaining to the CS and its draining veins on multidetector computed tomography angiography along with their clinical importance.

Surgical management of a giant right coronary artery aneurysm with coronary arteriovenous fistula: case report

Background

Coronary artery aneurysms (CAAs) are uncommon, and giant aneurysms (>2 cm) are even more unusual. Coronary atherosclerosis and Kawasaki disease are the leading causes for this pathology. The treatment for this condition is controversial because the evidence is based on case report series.

Case summary

We describe the case of a 77-year-old female patient who presented with heart failure symptoms. She was diagnosed with a giant saccular aneurysm arising from the right coronary artery (RCA) ostium and a fistula between the RC and the left anterior descending artery (LAD) to the coronary sinus. And an atrial septal defect (ASD) and severe tricuspid regurgitation were also found. The patient underwent surgery through a medium sternotomy, the aneurysm was opened and resected under cardiopulmonary bypass. The RCA was ligated at the distal end of the aneurysm, and a saphenous vein graft bypass was performed. A coronary arteriovenous fistula from the distal portion of RC and LAD artery to a severely enlarged coronary sinus was found and corrected with an autologous pericardial patch. Closure of the ASD was performed with a pericardial patch and a tricuspid ring annuloplasty was done. Post-operative course was uneventful.

Discussion

There are few cases of giant coronary aneurysms associated with fistulas reported in the literature. Despite the endovascular percutaneous techniques available to treat these patients, we believe that surgical treatment was the best option for this particular case. We consider that surgical treatment is a very good option for giant CAAs associated with AV fistulas that are not susceptible for current endovascular available devices. The literature lacks evidence regarding the best approach for these cases, and we think that invasive treatment should be tailored according to the heart's anatomy and patient risk.

Coronary artery fistula in adults: Incidence and appearance on cardiac computed tomography and comparison of detectability and hemodynamic effects with those on transthoracic echocardiography

BACKGROUND

The widespread use of cardiac computed tomography (CT) has increased the incidental discovery of fistulas of the coronary artery (CAF). This condition is rare and can affect hemodynamic parameters, but few reports focus on its hemodynamic effects. We investigated the frequency and types of CAF on CT and compared them with those of transthoracic echocardiography (TTE) to evaluate the detectability of CAF and its hemodynamic effects.

MATERIALS AND METHODS

We retrospectively evaluated cardiac CT images of 6789 adult patients who underwent imaging from January 1, 2013 through September 30, 2019 at our institution. We assessed the CT images for the presence of CAF and compared our findings with those obtained by TTE in control cases without CAF.

RESULTS

The prevalence of CAF determined with cardiac CT was 0.91%, with the left anterior descending artery (67.7%) as the most common site of origin and the main pulmonary artery (82.3%) as the most common origin of drainage. The incidence of aneurysm accompanying CAF was 48.4%. Color Doppler in TTE demonstrated abnormal flow that would suggest the presence of CAF of only 23.1%. Echocardiographic findings of hemodynamics did not differ significantly between patients with and without CAF nor between elderly and non-elderly patients with CAF.

CONCLUSIONS

Our study revealed differing prevalence and types of CAF from those reported using coronary angiography and little impact of CAF on hemodynamics. Color Doppler in TTE did not readily depict abnormal flow that might suggest the presence of a fistula, but cardiac CT allowed noninvasive and comprehensive assessment of CAF. Thus, we believe the acquisition of cardiac CT is necessary to establish the cause of continuous murmur that is not identified with TTE.

Cardiac tamponade due to ruptured coronary-pulmonary artery fistula aneurysm: a case report

Background

Coronary artery fistulas are rare and most commonly asymptomatic; however, they can become enlarged and rupture in some cases.

Case summary

We report a case of a 51-year-old woman who was brought to our hospital unconscious in an ambulance. Cardiac tamponade caused by the rupture of an aneurismal coronary-pulmonary artery fistula (CPAF) was detected by contrast-enhanced computed tomography and confirmed by invasive coronary angiography. Due to prompt diagnosis and subsequent surgical intervention, the patient’s condition was rapidly improved, and she was discharged from the hospital.

Discussion

Coronary-pulmonary artery fistula aneurysm rupture requires rapid diagnosis and treatment, and thus, in cases with cardiac tamponade and coronary aneurysm, CPAF aneurysm rupture should be considered.

Case Report: Surgical Treatment of High-Flow Coronary Fistulas for the Pulmonary Artery

Coronary fistulas are rare anomalies that can affect approximately 1% of the population, presenting few specific symptoms, and are often found occasionally in coronary angiography. Here we describe the case of a 61-year-old patient with complaints of precordialgia and dyspnea since adolescence, with late diagnosis of coronary fistulas with drainage to the pulmonary artery, and with unsuccessful percutaneous treatment.

Therefore, she underwent open surgery for the correction of the already known fistulas, in addition to the hemangioma involving such vessels, which made the understanding and resolution of this case more complex.

Atypical Presentation of Coronary Artery Fistula: Case Report and Review of the Literature

Chest pain is one of the common complaints a patient presents to the healthcare provider. It needs prompt evaluation to determine the cause and origin. Angina occurs when myocardial oxygen demand exceeds oxygen supply; the clinical manifestation is often chest discomfort. Atherosclerotic disease is the major cause of angina. However, several non-atherosclerotic conditions have been studied and reported in the literature that causes angina in rarity. We describe a case of coronary artery fistula (CAF) likely causing angina.

Successful transcatheter closure of coronary artery fistula in a patient with anomalous aortic origin of the left main coronary artery from the right aortic sinus

Transcatheter closure is an established method to treat coronary artery fistula (CAF). We present transcatheter closure in a 6-year-old girl with CAF and anomalous aortic origin of the left main coronary artery from the right aortic sinus. The CAF originated from the left coronary artery (LCA), coursed through the interventricular septum (intraseptal course) with prominent dilation, and drained into the right ventricular outflow tract. She underwent transcatheter closure and was in a stable condition at the 3-year follow-up with regression of the dilated portion of the intraseptal-type LCA. Hence, transcatheter closure of CAF is feasible in patients with anomalous origins of coronary arteries. <Learning objective: This report describes the feasibility and safeness of transcatheter closure of a coronary artery fistula in a patient with an anomalous origin of a coronary artery. This is the first report to visualize the regression of the markedly dilated left coronary artery with an intraseptal course.>.

Fistula occlusion and ligation for a giant right coronary artery aneurysm concurrent with right atrial fistula: a case report

Background

Coronary artery aneurysms in most cases require surgical treatment once diagnosed. Lifelong anticoagulation is often needed after surgery. We herein describe a 55-year-old man who was asymptomatic and diagnosed with right giant coronary artery aneurysm combined with right atrial fistula.

Case presentation

This is a case of asymptomatic giant right coronary artery aneurysm concurrent with coronary artery fistula. Because the aneurysm was in the distal right posterior descending coronary artery, right coronary artery ligation and fistula occlusion through the right atrium were performed in the absence of cardiopulmonary bypass. The aneurysm was excluded without impacting the myocardial blood supply, and the patient was exempted from lifelong anticoagulation regimen. The follow-up revealed favorable outcomes and the patient’s life expectancy was improved.

Conclusion

Decompression and exclusion without cardiopulmonary bypass can be adopted for distal coronary artery aneurysms that do not involve or only have a limited impact on distal blood supply. This procedure can exempt the patient from the lifelong anticoagulation regimen. In addition, the risk for myocardial ischemia caused by the thrombus in the aneurysm can also be avoided. The whole procedure is comparatively easy to perform.

Coronary artery fistulas detected with coronary CT angiography: a pictorial review of 73 cases

Coronary artery fistulas (CAFs) are abnormal connections of the coronary arteries that bypass the myocardial capillary bed and terminate into chambers of the heart or major blood vessels. CAFs are rare, and most of them are congenital. Because CAFs can be asymptomatic and detected incidentally, the true incidence is difficult to evaluate. CAFs usually have various and complicated image features, and the clinical symptoms mainly depend on the size, origin and drainage site of the fistulas. Thus, accurate imaging assessment of these characteristics is crucial for therapeutic planning and post-operative evaluation. Due to the high temporal and spatial resolution, coronary CT angiography has recently become more widely used in cardiovascular disease diagnosis, and more asymptomatic CAFs are accidentally found. Furthermore, with multiplanar reconstruction images, some complicated and subtle structures can be displayed more accurately. In this article, we reviewed the imaging features of CAFs on coronary CT angiography, mainly focusing on the pre- and post-operative anatomy displaying of these abnormalities.

Prevalence and Spectrum of Coronary Anomalies Detected on Coronary Computed Tomography Angiography: A single centre experience in Oman

Objectives

Coronary artery anomalies (CAAs) are uncommon congenital abnormalities with a prevalence ranging from 0.2–2%. CAAs can be asymptomatic or less commonly present with life-threatening symptoms. This study aimed to investigate the prevalence and spectrum of CAAs in patients who underwent coronary computed tomography angiography (CCTA) in Oman.

Methods

This retrospective study was conducted at the National Heart Centre, Muscat, Oman between September 2012 and August 2018. All consecutive patients who had undergone CCTA were included.

Results

A total of 4,445 patients were included in this study. Of these, 59 patients (1.3%) were diagnosed with CAAs with a mean age of 52.6 years (range: 12–80 years) and an equal gender distribution. Among the patients with CAAs, the majority (69.5%) had anomalous origins from the opposite or non-coronary sinus. Right coronary artery arising from the left coronary sinus was the most common type (33.9%). Fewer patients (18.6%) had left circumflex arising from the right coronary sinus (RCS). Seven patients (11.9%) had left main arising from the RCS. Other CAAs were in the dual left anterior descending artery (8.5%), high coronary artery take-off (6.8%), single coronary ostia (6.8%) and coronary artery fistula (6.8%).

Conclusion

The prevalence of CAAs was 1.3% which is similar to the literature.

Bilateral coronary-to-pulmonary artery fistulas associated with giant aneurysm in an elderly woman: Case report and literature review

Coronary artery fistula is an abnormal vascular communication of coronary artery with cardiac chambers or any segment of the systemic or pulmonary circulation. The prevalence is 0.9% of all coronary anomalies. Coronary artery fistula arises from the right coronary artery in approximately 50.0% of patients, from left coronary artery in approximately 42.0% of patients, and from both in approximately 5.0% of patients. Low-pressure structures are the most common sites of drainage of the coronary fistulas. If a large left-to-right shunt exists, it can be associated with potential complications, such as arterial aneurysm. Here we report an extremely rare case of a 76-year-old woman with bilateral coronary-to-pulmonary artery fistulas associated with giant aneurysms, detected by coronary angiography and confirmed with coronary computed tomography.

Coronary Artery Anomalies and Associated Radiologic Findings

Coronary anomalies occur in about 1% of the general population and in severe cases can lead to sudden cardiac death. Coronary computed tomography angiography and magnetic resonance imaging have been deemed appropriate for the evaluation of coronary anomalies by accurately allowing the noninvasive depiction of coronary artery anomalies of origin, course, and termination. The aim of this article is to describe and illustrate a comprehensive array for the classification of coronary artery anomalies.

Congenital aneurysmal right coronary artery with a fistula to the left atrium in an adult

Background

Congenital coronary artery fistula in association with aneurysm of the involved coronary artery in adults is rare. Moreover, the right coronary artery- left atrial fistula is also uncommon. Most of the cases are asymptomatic. However, symptomatic patients need therapeutic interventions. The potential complications associated with this anomaly are life-threatening, therefore, there is a need to explore more on differential diagnosis, investigations, management strategies and prevention of complications.

Case presentation

We present herewith a 26-year-old male patient with symptoms of chest pain and dyspnea. He was diagnosed with aneurysmal dilatation of the right coronary artery in its entire course which terminated as a fistulous communication into the left atrium. The closure of the fistula was done using autologous pericardial patch under cardiopulmonary bypass. Currently, the patient is being followed up after surgery and receiving anticoagulants.

Conclusion

The advancement in the diagnostic imaging modalities have made it possible to find similar abnormalities more frequently. Due to rare nature of this anomaly, there is a need to explore and discuss management strategies that include medical management, surgical intervention or percutaneous interventions for a successful outcome.

Significant incidental cardiac disease on thoracic CT: what the general radiologist needs to know

Objective

Incidental cardiac findings are often found on chest CT studies, some of which may be clinically significant. The objective of this pictorial review is to illustrate and describe the appearances and management of the most frequently encountered significant cardiac findings on non-electrocardiographically gated thoracic CT. Most radiologists will interpret multidetector chest CT and should be aware of the imaging appearances, significance, and the appropriate next management steps, when incidental significant cardiac disease is encountered on thoracic CT.

Conclusion

This article reviews significant incidental cardiac findings which may be encountered on chest CT studies. After completing this review, the reader should not only be familiar with recognizing clinically significant cardiac findings seen on thoracic CT examinations but also have the confidence to direct their further management.

The evaluation of coronary artery-to-pulmonary artery fistula in adulthood on 256-slice CT coronary angiography: Comparison with coronary catheter angiography and transthoracic echocardiography

OBJECTIVE

To review the imaging features of coronary artery-to-pulmonary artery fistula (CPAF) on CT coronary angiography (CTCA) and evaluate its diagnostic performance compared with coronary catheter angiography (CCA) and transthoracic echocardiography (TTE).

MATERIALS AND METHODS

We retrospectively reviewed with a diagnosis of CPAF from among 19855 consecutive CCTA performed with 256-slice MDCT scanner for suspected coronary artery disease. CT images were evaluated for - origin, number, size and course (tubular/worm-like dilation/significant aneurysm formation/wall attachment sign) of fistula vessels, drainage site, drainage site imaging features (pierced sign, isodensity sign, smoke sign, jet sign), and main pulmonary artery (MPA) enlargement. 25 patients of CPAF also underwent CCA and 47 patients underwent TTE.

RESULTS

There were 72 patients with CPAF (0.36%) in our study, of which 44 were men and 28 were women, with mean age of 55.8 ± 13.2 years (range 22-85 years). CPAF originated from conus artery, left anterior descending artery (LAD), combined conus artery and LAD in 55, 67, 50 cases, respectively. Tubular dilation, worm-like dilation and aneurysm was seen in 14, 58 and 35 cases, respectively. Wall attachment sign was noted in 69 cases. All the cases demonstrated only a single drainage site, with left lateral wall, left anterolateral, anterior, right lateral and right anterolateral walls of MPA in 44, 21, 5, 1 and 1 cases, respectively. The mean diameter of the fistula drainage site was 2.6 ± 1.3 mm. Pierced sign, jet sign, smoke sign, isodensity sign was seen in 72, 46, 41 and 24 cases, respectively. MPA enlargement was seen in 20 patients. CCA showed CPAF in only 20 cases among 25 patients; while TTE showed CPAF in only 9 patients among 47 patients.

CONCLUSION

CTCA is competent in detecting and characterizing CPAF with an excellent diagnostic performance as the first imaging modality of choice, which is valuable for giving a distinct and intuitive explanation to patients and physicians and making an objective and exact assessment for further management.

Anatomical variants and coronary anomalies detected by dual-source coronary computed tomography angiography in North-eastern Thailand

Purpose

Congenital coronary anomalies are uncommon, with an incidence ranging from 0.17% in autopsy cases to 1.2% in angiographically evaluated cases. The recent development of dual-source coronary computed tomography angiography (coronary CTA) allows accurate and noninvasive depiction of coronary artery anomalies.

Material and methods

A retrospective study included a total of 924 patients who underwent coronary CTA because of known or suspected coronary artery disease. In each study, coronary artery anomalies (CAs) were investigated.

Results

A total of 924 patients (mean age 51.2 ± 12.8 years), who underwent dual-source coronary CTA, were studied. The overall prevalence of CAs in our study was 3.7%, with the following distribution: four single coronary artery, 14 anomalous origin from opposite sinus of Valsalva, three absent left main, four high take-off coronary artery, three anomalous left coronary artery from pulmonary artery, and eight coronary artery fistulas.

Conclusions

The present study supports the use of coronary CTA as a reliable noninvasive tool for defining anomalous coronary arteries in an appropriate clinical setting and provides detailed three-dimensional anatomic information that may be difficult to obtain with invasive coronary angiography.

Coronary Artery Fistulae: Anatomy, Diagnosis and Management Strategies

Coronary artery fistula (CAF) is a relatively rare anatomic abnormality of the coronary arteries that afflicts 0.002% of the general population and represents 14% of all the anomalies of coronary arteries. Its clinical relevance focusses mainly on the mechanism of "coronary steal phenomenon", causing myocardial functional ischaemia even in the absence of stenosis, hence common symptoms are angina or effort dyspnoea. The suggested diagnostic approach is guided by the patient's symptoms and consists of a number of instrumental examinations like ECG, treadmill test, echocardiography, computed tomography scan, cardiac magnetic resonance and coronary angiography. If it is not an incidental finding, coronary angiography is required in view of the optimal therapeutic planning. Small-sized fistulae are usually asymptomatic and have an excellent prognosis if managed medically with clinical follow-up with echocardiography every 2 to 5 years. In the case of symptomatic, large-sized or giant fistulae an invasive treatment, by transcatheter approach or surgical ligation, is usually a reasonable choice, and both strategies show equivalent results at long-term follow-up. Antibiotic prophylaxis for the prevention of bacterial endocarditis is recommended in all patients with coronary artery fistulae who undergo dental, gastrointestinal or urological procedures. A life-long follow-up is always essential to ensure that the patient is not undergoing progression of disease or further cardiac complications.