Surgical treatment of a coronary artery fistula with concomitant saccular coronary artery aneurysm: a case report

Percutaneous coil embolization and stent implantation for multiple coronary-to-pulmonary artery fistulas with giant coronary aneurysms: a case report

Background

Multiple coronary-to-pulmonary artery fistulas (CPAFs) with giant coronary aneurysms (CAs) are extremely rare. The appropriate therapeutic indication and strategy for CPAFs have not been established.

Case summary

Herein, we report the case of an asymptomatic 74-year-old woman with multiple CPAFs associated with giant CAs that had gradually developed over a 4-year period. After heart team discussion, we were successfully treated by minimally invasive intervention using transcatheter coil embolization and coronary stent implantation to prevent ruptures.

Discussion

Coronary-to-pulmonary artery fistulas required evaluation of the appropriate timing of therapy initiation with reference to the presence of symptoms and fistula and aneurysm sizes, and determination of the optimal therapeutic approach with reference to the anatomy of the fistula with aneurysm and patient background characteristics.

Coronary to pulmonary artery fistula: morphologic features at multidetector CT

The objective of this study is to evaluate the incidence and morphologic features of coronary-pulmonary artery fistulas (CPAF) by multidetector computed tomography (MDCT). From 2006 to 2008, 5,372 patients underwent ECG-gated cardiac CT scans using 64-slice MDCT at our institute. Among them, 17 cases of CPAF were detected (M:F = 14:3, mean age = 63 years). Chief complaints of patients were chest pain (n = 12), abnormal cardiac test (n = 3), known coronary artery disease (n = 1), and known CPAF (n = 1). We retrospectively analyzed the morphologic features of CPAF, such as origin vessels, draining site, fistula size, and aneurysmal sac. Five cases underwent coronary angiography (CAG) and correlated with MDCT findings. Incidence of CPAF was 0.32% by MDCT. The origin of CPAF was the left coronary artery in five (29.4%), the right coronary artery in two (11.8%) and both coronary arteries in ten cases (58.8%). In regard to the diameter of the detected fistula, the diameter of the largest vessel excluding aneurysm was variable from less than 2 to 5.7 mm. Five patients (29.4%) had a fistula that was shown as one vessel that could be traced, one patient (5.9%) was shown as two vessels, and eleven patients (64.7%) were shown as innumerable multiple vessel networks. Five cases were associated with aneurysm (29.4%). Fistulas were located primarily in the left anterolateral aspect of the pulmonary trunk (82.3%) and mostly the drainage site was the left lateral side of the pulmonary trunk (82.3%). CAG was performed in five cases and revealed identical findings to MDCT. In conclusion, coronary-pulmonary artery fistula is more frequently found than anticipated on MDCT. CPAF is supplied by either single or both coronary arteries and drains to the left side of the pulmonary trunk. It is typically located in the anterolateral aspect of the pulmonary trunk. Sometimes CPAF is associated with aneurysms.

Coronary-pulmonary artery fistula diagnosed by multidetector computed tomography

Coronary-pulmonary artery fistula is an uncommon cardiac anomaly, usually congenital. Most coronary-pulmonary artery fistulas are clinically and haemodynamically insignificant and are usually found incidentally. This report describes a case of complex coronary-pulmonary artery fistula with two feeding vessels of separate origins: one from the proximal part of the left anterior descending artery and another arising from the right aortic cusp. The complex anatomy of the fistula was shown in detail by multidetector computed tomography using multiplanar reconstruction and 3D volume rendering techniques.

Coronary artery fistula with an associated aneurysm detected by 16-slice multidetector row computed tomographic angiography

We describe a case of a 60-year-old man with effort-induced angina pectoris. Coronary angiography showed an aneurysm in the proximal left anterior descending coronary artery. It was unclear whether it was a coronary artery aneurysm or a coronary fistula with an associated aneurysm. Three-dimensional reconstruction images from 16-slice multidetector row computed tomographic (MDCT) angiography showed an aneurysm that drained into the pulmonary artery. Images from 16-slice MDCT coronary angiography can be helpful in understanding complex coronary artery anatomy.

A Coronary Artery Fistula With Saccular Aneurysm Mimicking a Right Atrial Cystic Mass

A 16 year-old Korean girl with cardiomegaly was found to have a "right atrial cystic mass" on transthoracic echocardiography. An unusual cystic structure made the diagnosis difficult. However, transesophageal echocardiography and multidetector computed tomography revealed a coronary artery fistula with a distal saccular aneurysm involving the interatrial septum and draining into the right atrium. Multidetector computed tomography provided clear anatomic visualization that fully delineated the abnormal structures. Multidetector computed tomography may be considered as a good alternative for transesophageal echocardiography in assessing a tortuous coronary artery fistula and aneurysm with complex anatomy.

Rupture of an aneurysm resulting from a coronary artery fistula: a case report

A rare case of coronary-to-pulmonary artery fistulas associated with formation of a saccular aneurysm that ruptured into the pericardium occurred in a 69 year-old-female who had experienced an episode of unconsciousness 3 months earlier and who suffered a second episode. She was diagnosed as having a cardiac tamponade caused by rupture of a coronary artery aneurysm formed by a left coronary artery - pulmonary artery fistula. The hemorrhage stopped after pericardial drainage. She was referred for surgical treatment of the aneurysm and suture closure of the afferent coronary artery into the aneurysm, transpulmonary closure of the fistulas, and aneurysmorrhaphy. There was adhesion between the aneurysm and pericardium. Her postoperative course was uneventful and she has remained well for 4 months after the operation.

Huge saccular aneurysm in a coronary-pulmonary fistula fed by the left and right coronary arteries

A 62-year-old woman was referred because of an abnormal mediastinal shadow that had first been noted 4 years ago on the left cardiac border on plain chest roentgenogram and which had gradually increased in size since. A huge saccular aneurysm in coronary-pulmonary fistula into which both the left and right coronary arteries drained was revealed by computed tomography and coronary angiography. The patient underwent aneurysmal resection and ligation of the fistulas. Histological study of the aneurysmal wall did not reveal atherosclerotic change but instead cystic medial necrosis, although there was no other clinical manifestation associated with this.

Rupture of a giant saccular aneurysm of coronary arteriovenous fistulas

A 58-year-old Japanese woman was admitted to our hospital because of chest pain. A continuous murmur was detected at the left parasternal area. Electrocardiogram showed ST elevation in leads V2, V3 and V4. Chest computed tomography and echocardiography demonstrated pericardial effusion and a large mass which was adjacent to the pulmonary artery. An abnormal blood flow was detected in the mass by Doppler echocardiography. Coronary angiography confirmed that the mass was a giant aneurysm of coronary arteriovenous fistula arising from both the left and right coronary arteries. This patient had no symptoms until rupture of the fistula. Rupture of a coronary arteriovenous fistula is very rare but can be a cause of chest pain and pericardial effusion.