Coronary Artery Fistula From the Left Circumflex to Coronary Sinus

BACKGROUND

Coronary arteriovenous fistulas (CAVFs) are rare occurrences with an incidence of 0.1% to 0.9% on coronary angiography. Fistulas between the left circumflex coronary artery and coronary sinus are even less common.

CASE SUMMARY

A 71-year-old female underwent extensive diagnostic imaging for CAVF. Intervention with catheterized closure and coil embolization was planned but not performed due to disparate anatomy of the CAVF on echocardiogram, magnetic resonance imaging, computed tomography, and coronary angiography. Because of these discrepancies, there was an uncertain risk for distal embolization of the coils.

DISCUSSION

Variance in diagnostic interpretation from different imaging modalities can lead to difficulty in confirming the anatomy of a CAVF and hinder resolution. Best-practice diagnostic imaging and treatment options for CAVFs are discussed.

TAKE-HOME MESSAGES

Fistulas between the LCX and CS are rare, and their characteristics, origin, and termination can be difficult to determine without appropriate imaging modalities. This case highlights the efficacy of different imaging and treatment options for CAVFs.

Coronary Artery Fistula From the Left Circumflex to the Superior Vena Cava: Surgery and Follow-Up

BACKGROUND

A coronary artery fistula (CAF) is an abnormal connection between a coronary artery and another cardiovascular lumen.

CASE SUMMARY

The authors report a case of a large CAF originating from the left circumflex (LCX) and draining into the lower segment of the superior vena cava, resulting a shunt ratio of 1.3. The patient also had a severe bicuspid aortic valve insufficiency and ventricular dilatation yet remained asymptomatic. A single surgical procedure was performed to address both the fistula and the valvular pathology. Postoperative computed tomography angiography revealed a reduced LCX diameter proximal to the fistula site, with evidence of smooth plaque/mild thrombosis in the LCX walls. In addition, the coronary calcium score was high. The patient was on anticoagulant and statins, with low-density lipoprotein level of 1.3 mmol/L.

DISCUSSION

A CAF between the LCX and superior vena cava is exceedingly rare, with limited cases reported and no established management guidelines, complicating clinical decision-making.

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.

Left Coronary Artery-Right Ventricle Fistula Case Report: Optimal Treatment Decision

Coronary artery fistulas (CAFs) are rare congenital anomalies, presenting in 0.05-0.9% of cases, characterized by an aberrant connection between a coronary artery and a cardiac chamber or great vessel. Clinical manifestations can include heart failure, myocardial ischemia due to coronary steal, arrhythmias, or infective endocarditis. We report a case of a 39-year-old man initially evaluated in 2016 for peripheral edema and suspected right ventricular (RV) abnormality. Earlier assessments indicated a left anterior descending (LAD) coronary artery-RV fistula, but initial catheterization was nondiagnostic. Transthoracic echocardiography (TTE) revealed a dilated left coronary artery (LCA) and an RV apex aneurysm, confirmed by CT and coronary angiography, showing a 14 mm LAD fistula with large aneurysmal sacs (45.6 × 37.3 mm). Cardiac MRI demonstrated a tortuous LAD fistula draining into RV aneurysmal sacs with preserved biventricular function. Surgical intervention was recommended, but the patient declined and was lost to follow-up until 2022, being asymptomatic. Re-evaluation showed progression in aneurysm size (47 × 45 mm and 16 × 18 mm) without ventricular functional change. Follow-up TTE in 2023 indicated stable findings. This case emphasizes the necessity of multimodal imaging (TTE, CT, MRI, angiography) for CAF diagnosis and management planning. Given the variability in CAF presentation and outcomes, individualized management-including surgical, percutaneous, or conservative strategies-is crucial. Persistent follow-up is essential for monitoring potential complications and guiding treatment, even in asymptomatic patients refusing intervention.

Traumatic injury of the left anterior descending coronary artery with fistula to the right ventricular outflow tract postgunshot wound

Coronary artery fistulas (CAF) are rare abnormalities involving a connection between a coronary artery and an adjacent vessel or heart chamber. Here we discuss the case of a 47-year-old male patient who had multiple gunshot wounds (GSWs) to the chest and abdomen, suffering a through and through bullet wound to the heart from the left ventricle (LV) through the left anterior descending (LAD) coronary artery and exiting from the right ventricle (RV). At the time of his hospitalization, he underwent a non-ECG gated trauma CT scan and subsequent cardiac catheterization that showed patient has a CAF between the LAD and RVOT. Roughly 3 years after his injury, the patient had an ECG-gated coronary CT scan showing the CAF is still present. The patient is now experiencing symptoms of heart failure with suspected worsening of shunt flow from the fistula. This case sheds light on CAFs, their presentation and potential complications to raise awareness for clinicians and radiologists.

Successful transcatheter coil embolization of a coronary cameral fistula in a young male with a structurally normal heart: A case report

INTRODUCTION AND IMPORTANCE

Coronary-cameral fistulas (CCFs) are the anomalous connection between a coronary artery (CA) and a great vessel or cardiac chamber. About 90 % of CA fistulas are congenital and are related to persistent sinusoids during the embryonic period. Most fistulas originate from the right and left anterior descending CAs. The circumflex CA is rarely involved.

CASE PRESENTATION

A 20-year-old male was referred to a tertiary children's heart hospital center due to retrosternal chest pain (CP) and dyspnea on exertion (functional class Ш). The transthoracic echocardiography (TTE) was done, and it demonstrated a dilated left coronary artery (LCA) (size:5 mm) with a large aneurysm (2 cm) and a small orifice to the right ventricle (RV) body. Then, cardiac angiography was done, and dilated LCA and CCF were demonstrated in the RV. Subsequently, the aneurysm was occluded by eight coils.

CLINICAL DISCUSSION

CCAs can be treated by transcatheter approach or surgical repair. In the presented case, we planned to treat this condition through Cardiac Angiography. Cardiac Angiography was done, and eight coils occluded the aneurysm. The day after the angiography, the symptoms were completely resolved, and the patient didn't complain of CP and dyspnea.

CONCLUSION

CCFs represent an uncommon cardiac anomaly with diverse anatomical variations and clinical manifestations. Coronary angiography (CAG) is the most accurate diagnostic test to determine fistula anatomy and possible therapeutic options. Small symptomatic and large fistulas, regardless of symptoms, necessitate intervention through either a transcatheter approach or surgical repair.

Coronary Artery Anomalies: Diagnosis & Management

Coronary artery anomalies encompass a spectrum of congenital abnormalities affecting the origin, course, or termination of the major epicardial coronary arteries. Despite their rarity, coronary artery anomalies represent a significant burden on cardiovascular health due to their potential to disrupt myocardial blood flow and precipitate adverse cardiac events. While historically diagnosed postmortem, the widespread availability of imaging modalities has led to an increased recognition of coronary artery anomalies, particularly in adults. This review synthesizes current knowledge on the classification, mechanisms, and clinical implications of coronary anomalies, focusing on prevalent variants with significant clinical impact. We discuss strategies for medical and surgical management, as well as contemporary screening recommendations, acknowledging the evolving understanding of these anomalies. Given the breadth of possible variants and the limited data on some presentations, this review provides a framework to aid clinicians in the recognition and management of coronary anomalies, with a particular emphasis on their stratification by anatomical location. By consolidating existing knowledge and highlighting areas of uncertainty, this review aims to enhance clinical decision-making and improve outcomes for individuals with coronary anomalies.

Stable angina revealing a post-traumatic coronary cameral fistula: A case report

Coronary-cameral fistulas are abnormal connections between coronary arteries and any of the heart chambers, It may be acquired or congenital (whether isolated or along with congenital heart diseases); It is usually asymptomatic in younger patients; but with increasing age, symptoms begin to appear, and the incidence of complication rises. Coronary angiography is the gold standard in diagnosis but echography and cardiac magnetic resonance imaging may be also useful. It can be treated medically with β-blockers or calcium channel blockers, but large fistulas with hemodynamic significant shunts should be closed by transcatheter or surgical means. We present a 57-year-old patient with a history of chest trauma, that present fistulas connecting the 3 coronary arteries to the left ventricle chamber complicated by myocardial ischemia causing stable angina.

Giant Coronary-Pulmonary Artery Fistula Incidentally Detected in a Patient Presenting With Acute Inferior Myocardial Infarction

Coronary artery fistulas are abnormal connections between the coronary arteries and the heart or other surrounding vascular structures. Although they are usually congenital, they can also occur iatrogenically or due to trauma. They are usually asymptomatic, but they can cause serious and even fatal complications. These complications include myocardial infarction, embolism, thrombosis, arrhythmia, and rupture. In a 54-year-old woman admitted to the emergency department with an acute inferior myocardial infarction, a giant coronary-pulmonary artery fistula was detected on angiography. The fistula could not be closed percutaneously, and computed tomography angiography (CTA) revealed extensive aneurysms and diffuse calcifications. Large fistulas should be closed due to the risk of rupture. Small fistulas should be detected by CTA, and radiologists should be familiar with the imaging features.

Prevalence and characteristics of coronary artery fistulas among 20 259 patients undergoing invasive coronary angiography

BACKGROUND

Coronary artery fistula (CAF) is a rare coronary anomaly. This study aimed to investigate the prevalence, clinical features, and imaging characteristics of CAF among patients undergoing coronary angiography (CAG).

METHOD

This was a retrospective study including 20 259 consecutive patients (12 458 were male) who underwent CAG at our institution from September 2018 to March 2023. Electronic angiography records were reviewed, and a total of 86 (0.42%) CAF patients were enrolled and analyzed.

RESULT

Of the 86 CAF patients, 42 (49%) were male. Thus, the prevalence of CAF for males and females was 0.34% and 0.56%, respectively. Arrhythmia, left ventricular (LV) hypertrophy, LV dilation, and LV systolic dysfunction were observed in 38, 25, 10 and 5 cases, respectively. Among the 86 CAF patients, a total of 117 CAFs were detected. 61 (71%) patients had a single CAF, and the remaining 25 (29%) patients had multiple CAFs. Of the 117 CAFs, the most common origins and terminations were the left anterior descending artery (n = 50) and the pulmonary artery (n = 73), respectively. The CAF diameters were greatly varied, ranging from unmeasurable to 7.8 mm, and 22 (18%) CAFs were larger than 3 mm.

CONCLUSION

In the present study, the prevalence of CAF was 0.42% with a female predilection. Arrhythmia, LV remodeling and dysfunction were common. Seventy-one percent of patients had a single CAF. The left anterior descending artery and the pulmonary artery were the most common origin and termination of CAFs, respectively. Most CAFs were small, and 18% of CAFs were larger than 3 mm.

Computed tomographic-based three-dimensional printing of giant coronary artery fistulas to guide surgical strategy: a case series

Background

Coronary artery fistulas (CAFs) are abnormal communications between the coronary arteries and the heart chambers, arteries, or veins, potentially leading to significant shunting, myocardial ischaemia and heart failure. Computed tomographic (CT) angiography or conventional invasive angiography is the reference standard for the diagnosis of coronary fistulas. The fistula anatomy can become very complex, which makes surgical or interventional planning challenging.

Case summary

We report two cases of hugely dilated and tortuous coronary circumflex artery fistulas draining into the coronary sinus. Both patients were followed up for more than 10 years because of very complex coronary fistula anatomy and mild symptoms. From two-dimensional (2D) sliced CT images alone it, was uncertain whether surgery was feasible. However, since both patients had symptom progression (Patient 1 developed heart failure, and Patient 2 had recurrent pericardial effusions), three-dimensional (3D) heart models were printed for better understanding of the complex fistula anatomy and improved surgical planning. Both patients had successful surgery and symptomatic relief at follow-up.

Discussion

The delay in surgery, until clinical deterioration, may partly be a consequence of a general reluctance in performing complex surgery in patients with CAFs. As of now, CT-based 3D printing has primarily been used in isolated cases. However, 3D printing is evolving rapidly and supplementing 2D sliced CT images with a physical 3D heart model may improve the anatomical understanding and pre-surgical planning that could lead to better surgical outcome.

Minimally invasive coil embolization for significant left-to-right shunts due to giant coronary-to-pulmonary artery fistulas: a case report

Background

Coronary-to-pulmonary artery fistula (CPF) is a rare disease, and its optimal treatment strategy remains controversial. Herein, we report a rare case of minimally invasive coil embolization of giant CPFs.

Case summary

A 78-year-old man with a history of persistent atrial fibrillation and lumbar canal stenosis presented to our hospital with breathlessness. Cardiac computed tomography revealed giant CPFs inducing a significant left-to-right shunt (Qp/Qs 1/2.1) with a coronary artery aneurysm smaller than the size indicated for surgical treatment. To reduce the left-to-right shunt flow, coil embolization procedures for the fistulas were performed twice. Initially, the fistula arising from the right coronary artery was embolized using three Target® XXL (6 × 40 mm, 5 × 20 mm) and two Target® XL SOFT (4 × 12 mm) coils (Stryker Inc., Tokyo, Japan). One month later, the fistulas arising separately from the left coronary artery were embolized. After the procedures, the major shunt flow disappeared angiographically, and Qp/Qs significantly decreased to 1/1.2. Additionally, the fractional flow reserve of the left coronary artery increased from 0.79 to 0.93, and cardiopulmonary exercise testing showed an improvement in his exercise tolerance.

Discussion

In similar cases, a surgical procedure with ligation of the CPFs combined with resection of a small aneurysm and coronary artery bypass grafting would normally have been considered the best approach. However, endovascular treatment targeting only the fistulas was a superior strategy considering the patient's age. The coil embolization technique effectively controlled the shunt flow of the CPFs. This technique is considerably less invasive than surgical therapy.

Coil Embolization of a Left Anterior Descending Coronary Artery-Pulmonary Artery Fistula: A Case Report

Coronary artery fistulas may be defined as abnormal connections between a coronary artery and either a heart chamber or the pulmonary artery. Although usually asymptomatic, they can become enlarged and rupture in rare instances, requiring prompt intervention. We present a case of a 66-year-old male patient with a left anterior descending-pulmonary artery fistula managed with coil embolization.

Case report: Right coronary artery to left ventricular fistula complicated with coronary artery dilation presenting as persistent cardiogenic ischemic chest pain

We reported a patient with a fistula of the right coronary artery to the left ventricle, accompanied by dilation of the right coronary artery and persistent chest pain. This patient underwent surgical fistula closure surgery, but the fistula recurred. Persistent chest pain reappeared after encountering COVID-19 infection. We analyzed the mechanism of persistent myocardial ischemic chest pain caused by coronary artery fistula in this patient, the impact of surgery on the patient's disease, the possible mechanism of COVID-19 causing persistent ischemic chest pain in this patient, and the possible mechanism of metoprolol in alleviating myocardial ischemic chest pain in this patient.

Cinematic rendering of the coronary-pulmonary arterial fistula

Coronary-pulmonary arterial fistula is a rare coronary artery abnormality disease, which refers to a coronary fistula that terminates at the pulmonary artery. Coronary-pulmonary fistulas are much less common in children than in adults, and the small fistulas are easily missed. We report the case of a 9-year-old girl who presented with coronary-pulmonary arterial fistula. She underwent multimodal imaging, including chest X-ray, echocardiography, computed tomography with 3-dimensional cinematic rendering. We found that the cinematic rendering images clearly showed the small-caliber fistulous connections. The combination of CT and echocardiography can effectively help doctors understand the anatomical details and hemodynamic information.

An unusual case of coronary artery fistula successfully treated by transcatheter approach

Coronary artery fistulas are rare, but one of the most common forms of congenital coronary abnormalities. These patients are often diagnosed incidentally undergoing coronary angiography, but with the advent of novel cardiac imaging tools, there is an increasing rate of detection as well as transcatheter management of these fistulas. Our case is unusual in a way that it involved a combination of two separate coronary artery fistulas arising from both the coronary systems draining into the same site.

Coronary steal: how many thieves are out there?

The colorful term "coronary steal" arose in 1967 to parallel "subclavian steal" coined in an anonymous 1961 editorial. In both instances, the word "steal" described flow reversal in the setting of an interconnected but abnormal vascular network-in one case a left subclavian stenosis proximal to the origin of the vertebral artery and in the other case a coronary fistula. Over time, the term has morphed to include a larger set of pathophysiology without explicit flow reversal but rather with a decrease in stress flow due to other mechanisms. This review aims to shed light on this phenomenon from a clinical and a pathophysiological perspective, detailing the anatomical and physiological conditions that allow so-called steal to appear and offering treatment options for six distinct scenarios.

Coronary Artery Anomalies: A Short Case Series and Current Review

Coronary artery anomalies (CAAs) are rare congenital cardiovascular defects that can present in various ways depending on the origin, course, and termination of the abnormal coronary artery fistula. It is sometimes detected incidentally during procedures such as coronary angiography or autopsies. While adults with this condition are often asymptomatic, some may experience angina, congestive heart failure, myocardial infarction, cardiomyopathy, ventricular aneurysms, or sudden cardiac death (SCD). In fact, it is the second leading cause of SCD among young athletes and requires more studies to handle such patients efficiently. To illustrate the many possible manifestations of this unusual diagnosis, we present a series of five cases. We have also reviewed the different varieties of this rare congenital anomaly and discussed the latest diagnostic tests and treatment plans.

A Coronary Cameral Fistula Associated With Incessant Ventricular Arrhythmias

Coronary cameral fistula (CCF) is a rare congenital abnormality of abnormal communication between coronary arteries and cardiac chambers. Most patients are asymptomatic, while symptomatic patients are usually present in childhood. Adult patients can present with angina, heart failure, or arrhythmias. We report a rare case of CCF with associated recurrent torsade de pointes (TdP) in the absence of ischemic heart disease and electrolyte abnormalities.

Benign incidental cardiac findings in chest and cardiac CT imaging

With the continuous expansion of the disease scope of chest CT and cardiac CT, the number of these CT examinations has increased rapidly. In addition to their common indications, many incidental cardiac findings can be observed when carefully evaluating the coronary arteries, valves, pericardium, ventricles, and large vessels. These findings may have clinical significance or risk of complications, but they are sometimes overlooked or may not be described in the final reports. Although most of the incidental findings are benign, timely detection and treatment can improve the management of chronic diseases or reduce the possibility of severe complications. In this review, we summarized the imaging findings, incidence rate, and clinical relevance of some benign cardiac findings such as coronary artery calcification, aortic and mitral valve calcification, aortic calcification, cardiac thrombus, myocardial bridge, aortic dilation, cardiac myxoma, pericardial cyst, and coronary artery fistula. Reporting incidental cardiac findings will help reduce the risk of severe complications or disease deterioration and contribute to the recovery of patients.

Surgical Management of a Large Right Coronary Artery to Left Ventricle Fistula in a Neonate: A Case Report

A fistula from the right coronary artery draining into the left ventricle is a rare form of coronary artery fistula. Here, we describe the case of a symptomatic neonate with a large fistula of this type. The neonate was successfully treated with surgical closure of the fistula.

A Complicated Case Report of Coronary Artery Fistula

Background

Coronary artery fistulas (CAFs), also, known as coronary arteriovenous malformation, are aberrant connections between coronary arteries and other structures, such as other artery branches or heart chambers. CAFs are infrequent and asymptomatic in young patients, but symptoms and complications become more frequent with age. CAFs can affect hemodynamic parameters and lead to complications, such as myocardial ischemia, heart failure, arrhythmia, and infective endocarditis.

Objective

The aim of this article was to present a typical CAF case with severe symptoms who underwent successful embolization to resolve their symptoms.

Case presentation

A 50-year-old Vietnamese male visited our cardiac outpatient clinic (S.I.S General Hospital, Can Tho, Vietnam) because of exertional dyspnea and chest pain. Signs of congestive heart failure and abnormal murmur were not presented on chest auscultation. Diagnostic digital subtraction angiography was performed to determine the detailed angioarchitecture of the CAF, revealing a fistulous connection between the left anterior descending artery (LAD) and the LV chamber through an aneurysm. In addition, the RCA measured 7 mm in diameter with a fistula (16 × 9 mm) draining into an aneurysm and then terminating into the LV chamber. The patient had an RCA aneurysm with a fistula into the LV. It was treated successfully by closing the fistula with a vascular plug. Access to the fistula was complex and difficult because of complications due to the CAF. After the procedure, the patient had no chest pain or shortness of breath and was discharged after three days. After six months, he was taking dual antiplatelet therapy and antihypertensive medications and felt better. We performed contrast computed tomography (CT) to examine the fistula after a year, which showed the successful closure of the fistula without any relevant alteration in the coronary artery.

Conclusion

CAF closure is indicated if patients have symptoms or secondary complications, and percutaneous closure is a safe and effective method to manage CAF. A CAF is rare and does not have specific symptoms, making it difficult to diagnose. Most patients are asymptomatic and have serious recent complications. Currently, the percutaneous transcatheter method is popular because it is noninvasive and successful in most patients.

Dual Coronary-Pulmonary Artery Fistula in a Patient with Severe Bicuspid Aortic Valve Stenosis

A 62-year-old male presented to the emergency department with acute viral bronchitis and worsening of his chronic dyspnea on exertion. Incidentally, a murmur was detected on physical examination. Extensive work-up, including coronary computed tomography angiography, revealed a rare combination and potential association between severe bicuspid aortic valve stenosis and coronary-pulmonary artery fistulas.

An atypical cause of chest pain

Congenital coronary artery anomalies are of major significance in clinical cardiology and cardiac surgery due to their association with myocardial ischaemia and sudden death. Having a multidisciplinary approach in managing complex congenital conditions and including patients in the management decisions is essential for good doctor-patient relationship. Here within, we describe a complex coronary artery fistula leading to myocardial steal.

Monster left circumflex artery fistula closure by vascular plug in a patient with post-COVID-19 myocardial infarction

Herein, we report a man with a huge coronary fistula connecting the left circumflex coronary artery to the right ventricle. During the follow-up, the patient developed progressive symptoms of heart failure nonresponsive to medical treatment. Therefore, an endovascular closure with a vascular plug was successfully done for him. Transcatheter vascular plug occlusion can be considered as an alternative for closure of symptomatic high-flow large coronary artery fistulas in patients with a high risk of surgery and chance of coil dislocation, embolization, or unavailability of proper coils.

Case report: Multimodal imaging diagnosis of a giant coronary artery fistula: A report of two cases

Being a very rare cardiac disease, most cases of coronary artery fistula (CAF) are genetic. Complications such as coronary steal syndrome, myocardial infarction, heart failure, or tamponade can manifest following the abnormal communication that the fistula creates between the coronary arteries and cardiac chambers or major vessels and the subsequent shunt. Most CAFs are small and asymptomatic, making diagnosis difficult. In symptomatic patients, the initial diagnostic workup is generally made with chest radiography and electrocardiography. Other imaging modalities have also been suggested to improve diagnostic accuracy. Cardiac catheterization and coronary angiography are currently the gold standard for diagnosis and planning the intervention, as they can recognize the quantum of the shunt as well as complications of a fistulous track (e.g., aneurysm formation, thrombus, leak, and the number of openings to the receiving chamber/vessel); however, this invasive method may be associated with risk. Herein, we report two patients with giant CAFs, one from the left circumflex artery to the coronary sinus and the other to the superior vena cava. Moreover, we describe how multimodal imaging, including two- and three-dimensional transesophageal echocardiography, coronary cineangiography, coronary computed tomography angiography, and enhanced chest computed tomography, can facilitate diagnosis and estimate the disease course in such patients. We believe that using multimodal imaging cannot only help the initial diagnosis regarding the presence of a CAF and the accurate anatomical site of the fistula in the patient but can also help predict the disease course and choose the most suitable treatment modality. Therefore, we suggest multimodal imaging be done to diagnose patients suspected of CAF. However, invasive cineangiography should be necessarily followed, regardless of whether an intervention is planned or not.

A Case of Takotsubo Cardiomyopathy in a Patient With Coronary Artery Fistula

Takotsubo cardiomyopathy (TTC) is also known as stress-induced cardiomyopathy and mimics acute coronary syndrome in the setting of non-obstructive coronary artery disease. It is associated with reversible left ventricular apical, mid, and/or basal wall motion abnormalities. A coronary artery fistula (CAF) is a connection between one or more of the coronary arteries and the cardiac chamber or great vessel. We present a case of an elderly woman who presented with chest pain and was found to have non-obstructive coronary artery disease with wall motion abnormality pattern consistent with TTC and multiple CAF involving the left circumflex coronary artery and pulmonary artery. This case highlights a rare association between two uncommon entities.

[Prevalence of coronary anomalies detected by computed tomography at the Instituto Nacional Cardiovascular- INCOR]

Objective

: To determine the prevalence of coronary anomalies (CA) in patients evaluated by 64-detector computed tomography (CT) at the Instituto Nacional Cardiovascular in Peru between 2016 and 2020.

Materials and methods

Retrospective observational study, coronary artery CT scans of 1486 patients were performed on a 64-detector row CT scanner and reviewed in search for coronary anomalies.

Results

The prevalence of CA detected by CT was 4.71% (70 cases) of which 64.3% were male. Abnormalities of origin were the most frequent, of which the origin of a coronary artery from the opposite coronary sinus was the most common (48.6%), with the right coronary being the main anomalous artery (31%), and the main path was interarterial (31%). Anomalous origin of the left main coronary from the pulmonary artery was found in 5 patients. Among the anomalies of the intrinsic coronary arterial anatomy the most frequent was the double left anterior descending artery (10%). Coronary fistulas accounted for 11.4% of cases.

Conclusions

The prevalence of CA detected by 64-detector CT in a Peruvian institute was 4.71%. The most frequent coronary anomaly was the origin of the right coronary artery from the left coronary sinus with interarterial trajectory.

Coronary artery-bronchial artery fistula imaging characteristics and its correlation with pulmonary disease severity

Hemoptysis is a common clinical emergency, bronchial arterial embolization is considered to be an effective treatment. The presence of coronary artery-bronchial artery fistula (CBF) may lead to recurrence of hemoptysis after treatment. It is necessary to investigate the imaging characteristics of a CBF and its correlation with the severity of pulmonary disease. With the development of multi-detector computed tomography, our study used the 320-slice CT bronchial artery angiography technology to observe and visualize blood vessels. The image and clinical data of 2015 hemoptysis patients with 320-slice CT bronchial artery angiography were retrospectively reviewed from January 2015 to December 2019. The axial and three-dimensional CT images were analyzed. The incidence, anatomical characteristics of CBF and pulmonary disease severity score were evaluated. A total of 12 CBF vessels were detected in 11 patients. We found that the incidence of CBF in this group was 0.55% (11/2015). Mean CBF diameter was 1.9 mm (1.2-2.5 mm). The course of CBF usually was relatively fixed. The proportions of CBF originated from the left circumflex artery, right coronary artery, and left anterior descending artery were 75%, 16.7% and 8.3%, respectively. Preliminarily analysis of the correlation between the trend of CBF and the pulmonary diseases severity score showed that CBF was more likely to communicate with a bronchial artery on the side with a higher severity score. CBF may occur in patients with chronic pulmonary disease and hemoptysis, and its origin, course and trend are characteristic. Detailed and comprehensive computed tomography angiography image analysis is helpful to improve the clinical treatment of hemoptysis with CBF.

Coronary CT Angiography to Guide Percutaneous Coronary Intervention

Coronary CT angiography (CCTA) has emerged as a powerful noninvasive tool for characterizing the presence, extent, and severity of coronary artery disease (CAD) in patients with stable angina. Recent technological advancements in CT scanner hardware and software have augmented the rich information that can be derived from a single CCTA study. Beyond merely identifying the presence of CAD and assessing stenosis severity, CCTA now allows for the identification and characterization of plaques, lesion length, and fluoroscopic angle optimization, as well as enables the assessment of the physiologic extent of stenosis through CT-derived fractional flow reserve, and may even allow for the prediction of the response to revascularization. These and other features make CCTA capable of not only guiding invasive coronary angiography referral, but also give it the unique ability to help plan coronary intervention. This review summarizes current and future applications of CCTA in procedural planning for percutaneous coronary intervention, provides rationale for wider integration of CCTA in the workflow of the interventional cardiologist, and details how CCTA may help improve patient care and clinical outcomes. Keywords: CT Angiography © RSNA, 2022.

Left Circumflex Coronary Artery-to-Coronary Sinus Fistula with Coronary Sinus Ostial Atresia and a Persistent Left Superior Vena Cava in an Adult Patient

Understanding of coronary sinus (CS) anatomy and abnormalities is of critical importance due to their use in interventional procedures. Herein, the authors report a rare case of an asymptomatic 72-year-old man with a left circumflex coronary artery-to-CS fistula, together with CS ostial atresia and persistent left superior vena cava. These findings are described using both cardiac CT angiography and MRI with four-dimensional flow for anatomic and functional assessment. Keywords: Cardiac, Coronary Sinus, Aneurysms, Fistula, CT Angiography, MR Imaging Supplemental material is available for this article. © RSNA, 2022.

Case Report: Coronary-Pulmonary Fistula Closure by Percutaneous Approach: Learning From Mistakes

Coronary-pulmonary artery fistulas (CPAF) are congenital vascular anomalies detected incidentally in most cases. When a significant left-right shunt exists, surgical, or percutaneous treatment is indicated. We describe a challenging case of CPAF closure, by percutaneous approach, in a patient symptomatic for dyspnea and evidence of a significant left-right shunt. A first attempt to close the fistula was performed implanting a vascular plug but it quickly embolized. The plug was successfully retrieved. In a second attempt, we deployed several coils before implanting the vascular plug with total closure of the fistula. The combination of plugs and coils is associated with a higher success rate of closure.

Moorman A. Congenital systemic arteriovenous fistulas: Interventional strategies and embryological perspectives

Background:

Data on congenital systemic arteriovenous fistulas are largely based on individual case reports. A true systemic arteriovenous fistula needs to be differentiated from other vascular malformations like capillary or venous hemangiomas, which are far more common.

Objectives:

We sought to identify the varied symptoms, diagnostic challenges, describe interventional treatment options, and postulate an embryological basis for this uncommonly described entity.

Methods:

This is a descriptive study of a cohort of systemic arteriovenous fistulas seen in the department of pediatric cardiology at a tertiary cardiac institute from 2010 to 2020, with prospective medium-term follow-up. A total of seven cases were identified. The diagnosis was confirmed by computed tomographic imaging, magnetic resonance angiography, or conventional angiography.

Results:

All were successfully closed using duct occluders or embolization coils with no recurrence in six cases over a median duration of follow-up of 48 months (interquartile range: 16; 36–52 months). Four of the seven cases underwent follow-up imaging using echocardiography or ultrasound.

Conclusion:

The incidence of congenital systemic arteriovenous fistulas is low and accounted for 0.009% of pediatric outpatients seen over 10 years at our institute. The spectrum of clinical presentation varies from an innocuous swelling or a pulsating mass to frank heart failure. Strong clinical suspicion and advanced imaging modalities have helped identify some hitherto undescribed connections. Large malformations with multiple communications may persist or recur despite transcatheter closure.

Coronary Artery Anomaly, What Radiologist Should Know?

심장 전산화단층촬영(이하 CT)은 현재 관상동맥기형을 진단하고, 평가하는 가장 정확한 진단 도구로 자리매김하였으며, 심장 CT 촬영 건수가 증가함에 따라 관상동맥기형을 종종 관찰할 수 있다. 본 종설은 관상동맥기형에서 영상의학과 의사들이 꼭 알아야 할 대표적인 기형의 CT 소견들에 대해 다루었다. 관상동맥기형의 종류를 3부분 즉, 기시부, 동맥 내, 그리고 연결 부위로 나누어 설명하였으며, 임상에서 볼 수 있는 대표적인 기형들 중심으로 다루었다. 특히 혈역학적 이상을 유발하거나, 급사의 위험이 있는 기형들의 CT상 위험한 해부학적 소견에 대해서는 자세히 기술하였다.

Coronary Artery Fistulae in Adult: Two Decades of Experience in Clinical Presentation, Angiographic Feature, and Management

Coronary artery fistula (CAF) in adults is a rare but significant coronary artery anomaly. Main data on that rare disease were mostly obtained from case reports and small studies. In presented study, we share our two-decade experience on the clinical and angiographic characteristics of CAF. The data were collected retrospectively by analyzing the angiographic data between January 1, 2000 and December 31, 2019. Demographic data, clinical data, laboratory, and cardiac catheterization reports were reviewed. CAFs were found in 40 patients (0.06%). There were 22 male (55%) patients. The mean age was 61.2 years. Twenty-nine patients (72.5%) had small, 4 patients (10%) had medium, and 7 patients (17.5%) had large CAFs. The majority of study population had solitary CAF ( n  = 31, 77.5%). The pulmonary artery is the major side of fistula drainage ( n  = 20, 50%). The study population was divided into two groups as follow: group 1-small CAFs 29 (72.5%), group 2-medium and large CAF (MLCAF) 11 (27.5%). Patients with MLCAFs had more atrial fibrillation, abnormal coronary morphology, and multiple fistulae. In patients with hemodynamically significant CAFs, 7 (17.5%) patients had surgical ligation and 3 (7.5%) patients had transcutaneous closure. Three patients died during mean follow-up period of 5 years. The incidence and the pattern of CAFs in our study were similar to previous studies. Clinical course of small fistulae was benign. Symptomatic MLCAFs need to be treated by transcatheter or surgical way and should be individualized per patient.

Coronary artery-to-pulmonary artery fistula in adults: evaluation with 320-row detector computed tomography coronary angiography

Background

To analyze the imaging features of coronary artery-to-pulmonary artery fistula (CPAF) on coronary computed tomography angiography (CCTA).

Methods

This was a retrospective study of 3,975 patients who underwent 320 row detector CCTA examinations in our hospital from May 2015 to July 2020. A total of 22 patients who diagnosed with CPAF were reviewed for CCTA imaging characteristics, including the origin, number, blood volume, opening size, and course of fistula vessels, and the drainage site, size, and imaging features of the fistula. All cases were analyzed for the presence of coronary atherosclerotic plaque and that of deficient left ventricular myocardial perfusion.

Results

A total of 22 CPAF cases detected by CCTA were collected (men, 11; women, 11; median age, 59.6±10.1 years). There were 7, 10, and 5 cases detected with 1, 2, and 3 fistula vessels, respectively, among which 4 originated from the left coronary artery, 4 from the right coronary artery, and 14 had bilateral origins. There were 10 cases in which the fistula vessels presented as a worm-like tortuous dilation with (n=5) or without (n=5) aneurysm, while 12 cases showed malformed vascular networks with (n=8) or without (n=4) aneurysm, respectively. The calculated incidence of aneurysm formation was 59.09%, and fistula vessels with an aneurysm had larger blood volume than those without. All fistula showed a single drainage site, with an average diameter of 2.81±1.48 mm where the diameter of fistula with aneurysm was larger than that without. The fistula vessels drained into the left anterolateral and anterior walls of main pulmonary artery and the proximal left inferior PA, respectively. Typical jet sign, smoke sign, and isodensity sign were presented in 22, 14 and 1 case, respectively. For the coexistent abnormalities analyzed in 22 cases, 17 participants with CPAF demonstrated hypoperfusion of the fistula vessels, and 11 demonstrated calcified plaque accompanied with luminal stenosis to different degrees.

Conclusions

The 320-row detector CCTA can comprehensively characterize the morphological features of CPAF, which is an optimal choice for physicians to make an accurate assessment before formulating patient management strategies.

Coronary Artery Fistulas: A Review of the Current and Future Roles of Imaging

Coronary artery fistulas are uncommon but clinically important entities that may produce symptoms and significant complications such as angina, myocardial infarction, coronary artery aneurysm formation, and congestive heart failure. Multiple fistula types have been recognized, and classification uses factors such as etiology, coronary artery origin, and drainage site. Both invasive and noninvasive imaging play an important role in the management and treatment of these patients, and often times, more than one modality is necessary for comprehensive evaluation of coronary fistulas. Recent advances in both functional and anatomic imaging will likely also play a growing role in fistula evaluation. The purpose of this article is to review the classification, pathophysiology, clinical presentations, imaging findings, treatment, and future imaging directions of coronary artery fistulas.

Diverse Transcatheter Closure Strategies in Coronary Artery Fistulas A State-of-the-Art Approach

Coronary artery fistulas (CAFs) are accounted as the most congenital coronary anomalies. As their natural course is progressive dilatation of the feeder arteries and the fistula tract, so, catastrophic complications are frequently illustrated by aging. Even in those with asymptomatic small fistulas, close follow-up is mandatory to prevent subsequent sequelas. In patients with medium or large-sized fistulas, irrespective of symptoms, closure (either by surgical ligation or transcatheter closure) is recommended. In the current era of advances in the equipment and devices and also innovations in percutaneous closure techniques and preprocedural imaging, TCC is now regarded as the preferred strategy for CAF closure except in some high-risk cases. So, by appropriate case selection modalities, pre-procedural planning, and determining the closure techniques, recent small case-series studies have been reported good final angiographic and clinical results by TCC. In this article, we have introduced several transcatheter closure techniques by details; also, we have recommended more multi-center trials with long-term clinical follow-up to address the best treatment options in these patients.

Imaging Findings of Coronary Artery Fistula in Children: A Pictorial Review

Coronary artery fistula, defined as an abnormal communication between the coronary arteries and a cardiac chamber (most commonly) or a thoracic great vessel, may result in hemodynamically significant problems due to vascular shunting in children. Echocardiography, cardiac catheterization, cardiac MRI, and cardiac CT may be used to evaluate coronary artery fistula in children. Recently, CT has played a pivotal role for the accurate diagnosis of coronary artery fistula in children. Surgical or interventional treatment is performed for hemodynamically significant coronary artery fistulas. In this pictorial review, the detailed imaging findings of coronary artery fistula in children are described.