A case of four coronary artery fistulae originating from three vessels associated with aneurysm

A case of an aneurysm associated with four coronary artery fistulaeoriginating from three vessels is reported. The patient, a 52-year-oldwoman, had chest heaviness and palpitations. Coronary arteriographyreveaed the four fistulae originating from three coronary vesselswith an aneurysm draining into the left ventricle and the mainpulmonary artery.The patient's symptoms were relieved afterfistulectomy and the aneurysmectomy, suggesting that a coronarysteal phenomenon through the fistulae was the cause of her symptoms.This case is of interest because of its rarity, since this isthe first case report of an aneurysm associated with four coronaryartery fistulae from three vessels.     

Steal syndrome secondary to coronary artery fistulae associated with giant aneurysm

Giant coronary artery aneurysms and coronary artery fistulae are uncommon pathologies. We present the case of an elderly woman who was referred to cardiology for investigation of possible ischaemic heart disease prior to orthopaedic surgery. The patient had developed chest pain in the setting of a septic total knee replacement associated with changes on electrocardiography. Coronary angiography revealed multiple coronary arteriovenous fistulae associated with giant coronary artery aneurysm causing steal syndrome in the setting of haemodynamic stress.     

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

An extremely rare case of a coronary artery fistula with a concomitant saccular aneurysm is presented. A 65-year-old woman, who had a history of chest bruising 5 years earlier, suffered from chest pain, which was diagnosed as being due to left coronary artery-pulmonary artery fistulae concomitant with a giant saccular coronary artery aneurysm. Suture closure of the afferent coronary artery to the aneurysm, aneurysmorrhaphy, and transpulmonary closure of coronary artery-pulmonary artery fistulae were performed. The postoperative course was uneventful and the patient was well at 3 months after the operation. Because the risk of surgery appears to be less than the potential development of fatal complications, it is recommended for the treatment of coronary artery fistula with a concomitant saccular aneurysm.     

Bilateral coronaro-pulmonary fistula. Apropos of a new case with review of the literature

Two coronary pulmonary fistulae were demonstrated between the right coronary and left anterior descending arteries and the main pulmonary artery at coronary angiography, in a 66 year old woman with a continuous murmur in the third left intercostal space. This double malformation, though uncommon is not rare (18 previously published cases). It is usually diagnosed late (17 to 76 years) and the presentation is limited in half the cases to a localised continuous murmur, the localisation of which may simulate a patent ductus arteriosus. The hypothesis of a supernumerary coronary artery arising from the main pulmonary artery is suggested by the constancy of the anatomical characteristics of the reported cases. Eight patients presented typical attacks of angina which were due to severe coronary atherosclerosis, affecting two or three main vessels except in one case. Therefore, it is unlikely that these fistulae cause coronary insufficiency by a coronary steal syndrome. However, this mechanism may aggravate symptoms in patients with coronary artery disease and necessitate surgical cure of the fistulae at the same time as coronary bypass surgery. On the other hand, surgery does not seem to be indicated in asymptomatic patients.     

Left-circumflex coronary artery to right atrium fistula with saccular aneurysm and its endovascular treatment

The combination of coronary artery aneurysm and coronary artery fistula is infrequent. A saccular aneurysm of a branch of the left-circumflex coronary artery associated with multiple fistulae to the right atrium was observed on a coronary angiogram performed in a 47-year-old female. Multidetector computed tomography coronary angiography detailed the anatomy of the abnormal coronary artery. An embolization with a microcoil was performed and the aneurysm sac was excluded.     

Myocardial Infarction Caused by a Fistula between the Left Anterior Descending Coronary Artery and the Left Ventricle

Herein, we describe the case of a 50-year-old man who had a fistula, located between the left anterior descending coronary artery and the left ventricle, that caused myocardial infarction. Electrocardiography revealed a loss of R-wave progression in leads V₁ through V₄, and transthoracic echocardiography showed an apical aneurysm. Selective coronary angiography was performed. Dimensions of the left anterior descending coronary artery, and digital caliper measurements of stenosis within, were normal. After the injection of angiographic contrast material from the distal part of the left anterior descending coronary artery, a smoky, opaque accumulation colored the left ventricle. The digital caliper measurement of the left anterior descending coronary artery was again found to be normal. In the apex of the left ventricle, ventriculography in the left anterior oblique position revealed a small aneurysm, and a myocardial perfusion scan showed a fixed perfusion defect.Cases of coronary fistulae that result in myocardial infarction are rare. Because the patient had no ongoing symptoms after his myocardial infarction, medical therapy was prescribed.Key words: Angina pectoris/etiology, arterio-arterial fistulas/complications/congenital/diagnosis/radiography, coronary angiography, coronary vessel anomalies/complications/diagnosis/epidemiology/radiography, fistula/complications/congenital, heart ventricles/abnormalities/physiology, myocardial infarction/etiology, vascular fistula/complications/diagnosis/therapyCoronary artery fistula is a very rare cause of coronary artery disease, and it rarely causes coronary ischemia. Most affected patients are asymptomatic. Morphologically, coronary fistulae vary greatly, and they manifest themselves in widely differing clinical presentations; most often, respiratory difficulty and congestive heart failure accompany coronary fistulae. Investigators have reported that coronary artery fistulae can lead to symptoms of angina pectoris.^1–4 More rarely, fistulae can precipitate myocardial infarction.^1,2,4 Here, we present the case of a man in whom a coronary artery fistula caused myocardial infarction. We discuss coronary fistulae in general, and describe the treatment decided upon for our patient.     

Coronary-pulmonary artery fistula arising distal to obstructive coronary lesions.

We report 2 cases of coronary-pulmonary artery fistulae (CPF) arising distal to obstructive coronary artery disease. The fistula in the first patient was in the form of a tortuous dilatation of the distal portion of the right coronary artery and opened into the right pulmonary artery. In the second case, the fistula, a plexus of vessels, arose from the left anterior descending artery and entered the left pulmonary artery. Both the fistulae were successfully ligated at the time of concurrent coronary artery bypass graft surgery.     

Coronary artery aneurysm associated with aortitis syndrome diagnosed pre- and intraoperatively

Aneurysm of the coronary artery associated with aortitis syndrome is extremely rare. This is a case report of a left coronary artery aneurysm associated with aortitis syndrome. The patient was a 47-year-old woman who complained of palpitation and dizziness on exertion. Aortogram revealed occlusion of the arch vessels, infrarenal aortic stenosis, and a fusiform aneurysm of the left coronary artery. There was neither an intraluminal thrombus nor occlusive changes in the coronary arteries. Severe systolic hypertension nearing 300 mmHg was present in the ascending aorta. Severe hypertension and direct extension of inflammation to the coronary artery seemed to be important factors for the formation of the aneurysm. To resolve the severe hypertension, a bypass operation between the ascending aorta and the abdominal aorta distal to the stenosis was performed. The postoperative course was uneventful and blood pressure was reduced.     

Nonatherosclerotic aneurysm of the left circumflex coronary artery presenting with accelerated angina pectoris: response to medical management--a case report

Coronary artery aneurysm is defined as coronary dilatation with a diameter of more than 1.5 times the adjacent normal coronary artery. Most of the coronary aneurysms remain asymptomatic. More than 90% of coronary aneurysms are of atherosclerotic origin. Nonatherosclerotic coronary aneurysms are rare, and the majority of them are diffuse. Among the three major coronary arteries, the left circumflex artery is the least commonly involved. The management strategies for nonatherosclerotic coronary aneurysms are not clear, and each case should be managed on an individual basis depending on the clinical context. Here described is a case of a discrete nonatherosclerotic aneurysm of the left circumflex coronary artery in a 46-year-old man who presented with accelerated angina pectoris and was treated medically. The patient was free of symptoms on 2-year follow-up. The clinical perspectives of the nonatherosclerotic coronary aneurysm are discussed.     

Coronary fistula between the left anterior descending coronary artery and the pulmonary artery: Two case reports

Coronary artery fistulae are rare congenital or acquired connections between the coronary vessels and the cardiac chambers or other vascular structures. We present two consecutive cases of coronary fistulae between the proximal left anterior descending artery (LAD) and the main pulmonary artery. Both cases where admitted with history of acute coronary syndromes and had multivessel coronary disease along with coronary pulmonary fistulae. The two cases were managed by coronary artery bypass grafting (CABG) and repair of the fistulae.     

Primary congenital anomalies of the coronary arteries: a coronary: arteriographic study

Geographic variations in the incidence of different congenital coronary anomalies are well known, but infrequently studied in the Indian population. Among 4,100 adult patients who underwent diagnostic coronary arteriography, 39 (0.95%) patients (34 males, 5 females) had one or more anomalous coronary arteries. Their mean age was 46.4 +/- 8.2 years (range, 26-68 years). Thirty-five (89.74%) had anomalies of origin and distribution, while the remaining four (10.25%) had coronary artery fistulae. Right coronary artery was the commonest anomalous vessel, involved in 19 (48.74%) patients. It was originating from the left sinus of Valsalva in 15 and from the non-facing aortic sinus in four patients. Anomalous left circumflex artery was the second commonest anomaly, seen in 14 (35.89%) patients. Anomalous left anterior descending artery and anomalous left coronary artery from pulmonary artery were seen in one patient each. Among patients with coronary fistulae, two had fistulae between the left anterior descending artery and the main pulmonary artery, one between the conal artery and the right atrium, while the fourth patient had fistulae from the right coronary as well as from the left anterior descending artery to the left atrium. Atherosclerotic plaques in the anomalous arteries were seen in only 13 (33.33%) patients, much less than the overall incidence of coronary artery disease in patients with congenital coronary anomalies in this series (66.66%). In four (10.25%) patients, only the anomalous vessels were involved in coronary artery disease. Thus, in a small subgroup there does not appear to be an increased risk for development of atherosclerotic coronary artery disease in anomalous coronary arteries. Recognition of coronary anomalies is important in patients undergoing coronary arteriography, coronary interventions and cardiac surgery. Variations in the frequency of primary congenital coronary anomalies may possibly have a genetic background.     

Transcatheter embolisation of coronary artery fistulae

BACKGROUND: Most children with coronary artery fistulae are asymptomatic, but because of associated late morbidity, early intervention is usually indicated. AIM: To assess the outcome following transcatheter embolisation of coronary artery fistulae. PATIENTS AND METHODS: Six children, with a median age of 9.5 years (range: 1.3-13.7 years), underwent transcatheter embolisation of coronary artery fistulae. Four patients had simple fistulae, which drained from the right coronary artery to the right ventricle (n = 2), the left coronary artery to the right ventricle (n = 1), or the left coronary artery to the coronary sinus (n = 1). Two patients had complex multiple fistulae arising from both coronary arteries, which communicated with either the right ventricle or the pulmonary arterial system. RESULTS: A stable position with a 5-Fr coronary catheter was obtained proximally and a 3-Fr coaxial catheter was advanced through the coronary catheter to a distal position in the coronary artery fistulae. The number of embolisation microcoils used per procedure ranged from one to 12, and the coil diameter ranged from 3 mm. Polyvinyl alcohol foam embolisation particles (1000 microm) were used to embolise small fistulae to the pulmonary arterial tree. Complete occlusion was obtained in four patients, while two children were left with insignificant residual shunts. There were no early or late cardiac complications. CONCLUSION: Transcatheter embolisation of coronary artery fistulae is a safe and effective therapy in patients with suitable anatomy.     

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.     

Another cause of chest pain: Coronary artery—Pulmonary artery fistulae

This report describes three patients with coronary artery fistula from proximal left anterior descending artery to the pulmonary artery. Retrospective analysis of 2756 adults undergoing coronary arteriography for evaluation of angina pectoris between July 1988 and January 2000 revealed coronary artery fistulae in three patients: one male (46 years old) and two females (45 and 53 years old). No murmur was audible in any patient. There was no associated significant coronary artery disease. The feeder arteries to the fistulae for all three patients were left anterior descending coronary artery. One of the patients underwent cardiopulmonary bypass and the fistulae was ligated, due to very strong angina. The diagnosis is mostly incidental during routine coronary arteriography. We concluded that the coronary artery-pulmonary artery fistula might be a cause of angina without audible murmur and may sometimes need surgical ligation.     

Left main coronary artery stenosis associated with extremely long fusiform aneurysm

Coronary artery aneurysm is defined as coronary dilatation, which exceeds the diameter of normal adjacent segment or the diameter of the patient's largest coronary vessel by 1.5 times [Syed M, Lesch M: Coronary artery aneurysms: a review. Prog Cardiovasc Dis 1997; 40:77-10 84 [1]]. Most studies show an incidence of 1% to 2% [Barettella MB, Bott-Silverman C. Coronary artery aneurysm: an unusual case report and a review of the literature. Cathet Cardiovasc Diagn 1993; 29:57-61 [2]]. Left main coronary aneurysms (LMCA) are even more rare; in a study by involving 22,000 coronary angiograms an occurrence rate of 0.1% has been found [Topaz O, DiSciascio G, Cowley MJ, Goudreau E, Soffer A, Nath A et al. Angiographic features of left main coronary artery aneurysms. Am J Cardiol 1991; 67:1139-1142 [3]]. The majority of patients present with ischemic symptoms secondary to the coexisting atherosclerotic lesions and most of the coronary aneurysms are incidentally diagnosed by coronary angiography. This report details the exceptional case of a 62-year-old patient with "unusually long fusiform" aneurysm of the left main coronary artery associated with critical left main coronary artery distal stenosis involving the ostia of left anterior descending and left circumflex coronary artery. With this case the possible anatomic determinants of the type, location, and mechanism of aneurysm formation were also discussed.     

A Tortuous Road for Septic Pulmonary Emboli in Left-Sided Endocarditis

Coronary artery fistulae are rare congenital or acquired connections between the coronary vessels and the cardiac chambers or other vascular structures. We report a case of a woman with mitral valve endocarditis and multiple pulmonary septic emboli. Transesophageal echocardiography revealed a tortuous coronary fistula as the pathway for the septic emboli. The fistula, which originated from the right coronary artery to the right atrium, was visualized using different imaging modalities.     

Aneurysm of main left coronary artery.

A 57-year-old man presented with exertional chest pain, and was found to have a saccular, lobulated aneurysm of the left main coronary artery associated with severe atherosclerotic vascular disease. This is the third similar case reported and the first case of atherosclerotic origin. All symptoms were relieved by coronary artery bypass surgery.     

Primary congenital anomalies of the coronary arteries: a coronary arteriographic study in Western Turkey

Coronary artery anomalies are found in 0.6% to 1.5% of coronary angiograms. Angiographic recognition of these vessels is important because of their clinical significance and importance in patients undergoing coronary angioplasty or cardiac surgery. We reviewed the database of the Cardiac Catheterization Laboratory of Uludag Medical University in Bursa, Turkey. All patients who were subjected to coronary angiography from 1994 to 2001 were included. The study included 12,059 patients who underwent diagnostic coronary arteriography during the 8 year period. One hundred patients had primary congenital coronary anomalies. Ninty-five (95%) of the patients had anomalies of origin and distribution while five (5%) had coronary artery fistulae. The left main coronary artery (LMCA) was the most common anomalous vessel involved (forty-eight (48%) of the patients). An LMCA distribution anomaly was observed in these 48 patients. An anomalous right coronary artery (RCA) was the second most common anomaly, seen in twenty-two (22%) of the patients. An anomalous circumflex artery (Cx) was the third most common anomaly, seen in seventeen. Five patients had a coronary artery fistulae. The fistulae in our series were small without significant shunt circulation. Primary congenital coronary anomalies are isolated lesions and generally have no relation with other congenital heart diseases. They do not appear to be associated with an increased risk for development of coronary atherosclerosis. Angiographic recognition of these vessels is important because of their clinical significance and importance in patients undergoing coronary angioplasty or cardiac surgery.     

Congenital coronary artery fistula draining into the right ventricle: successful surgical closure after failed transcatheter coil embolization

Coronary artery aneurysms and fistulae are very rare congenital anomalies. They occur in 0.2-0.4 % of all congenital heart diseases. In this article, we report a case of a four-year-old girl with a right coronary artery aneurysm and fistula draining into the right ventricle. Since the transcatheter coil embolization was not successful, surgical occlusion was considered in this case. We describe and discuss the handling of the fistula and the aneurysmatic enlargement of the proximal coronary artery.     

Two-dimensional echocardiography of coronaro-cavitary fistulas

4 cases of congenital coronary arteriovenous fistulae in children 20 days to 10 years old were studied by 2D echocardiography. The coronary fistulae were treated surgically in all four cases after biplane aortography and selective coronary arteriography. The visualisation of the coronary arteries was performed by systematic use of several echocardiographic views: - left parasternal short axis view through the aortic root, - apical view, - longitudinal and transverse subcostal views. 3 cases of coronary fistulae between the right coronary artery and a cardiac chamber were diagnosed on the basis of significant dilatation (9 to 12 mm) of the right coronary artery, though the origin and diameter of the left coronary artery were normal. 1 case of a fistulae from a single left coronary artery was not diagnosed despite the demonstration of dilatation of the left main stem. Conversely, there were no false positive 2D echocardiographic diagnoses during the study period. The communication of the coronary fistula to the receiving cardiac chamber was demonstrated in two cases (right atrium: 1 case, left atrium: 1 case, on apical and subcostal views. It was not possible to visualise the communication of the coronary fistula with the right ventricle in the other two cases. 2D echocardiography is a non-invasive method of diagnosing coronary arteriovenous fistulae, but the development of a fistula on a single left coronary artery is a potential source of diagnostic error.