Coronary artery fistula in adults: evaluation with dual-source CT coronary angiography

Objective:

To evaluate the clinical value of dual-source CT (DSCT) coronary angiography in the diagnosis of coronary artery fistula (CAF) in adults.

Methods:

A large cohort of 17,548 patients, who underwent DSCT coronary angiography in our hospital between January 2008 and October 2013, were retrospectively reviewed for CAF. The origin, course and drainage site of CAF and coexisting abnormalities were analysed. The conventional angiography results, treatments and follow-up DSCT images were also evaluated.

Results:

A total of 33 CAFs from 17,548 patients were detected. The incidence of CAF was 0.19% by DSCT. CAF originating from the left coronary artery (LCA) was found in 14 (42.4%) patients, from right coronary artery (RCA) in 4 (12.1%) cases and from both LCA and RCA in 15 (45.5%) patients. The pulmonary artery was the most common site of drainage (28/33, 84.8%). 8 of the 33 (24.2%) cases were associated with aneurysms. Six cases were associated with coronary artery atherosclerosis. Four patients underwent conventional angiography.

Conclusion:

Coronary–pulmonary artery fistula in adults was found more often than in previous studies. CAF commonly originates from LCA or both LCA and RCA in adults. DSCT is a robust tool for investigating the origin, course and drainage site of CAF and coexistent abnormalities.

Advances in knowledge:

A large adult patient cohort who underwent DSCT angiography was reviewed to assess CAFs. Coronary–pulmonary artery fistula in adults was found more often than in previous studies. CAF was observed to originate from the LCA or both coronary arteries in adults. DSCT could clearly depict the fistula origin, course, drainage site and coexisting abnormalities. Conventional angiography results, treatments and follow-up DSCT images were analysed.Coronary artery fistulas (CAFs) are anomalous connections of the coronary arteries. The phenomenon was first described in 1865 by Krause.¹ CAF is considered as a major coronary anomaly by Ogden''s classification.² Most CAFs are congenital. CAFs have an estimated prevalence of 0.002% in the general population; however, they are present in 0.05–0.25% of patients who undergo coronary angiography.^3–5 The traditional diagnosis tool for CAFs is conventional angiography. With the advent of 64-slice multidetector CT in chest and cardiac imaging, the number of incidentally found CAFs has been increasing. The advanced electrocardiogram (ECG)-gated technique of dual-source CT (DSCT) could provide high diagnostic accuracy for the assessment of coronary artery disease.According to prior studies, CAF arises from the right coronary artery (RCA) in approximately 50% of patients.^6–8 In particular, 70% of the CAFs in children (mean age, 2.9 years) originated from the RCA.⁹ In this study, we focused on adult patients. A large cohort of adult patients who underwent DSCT angiography was reviewed to assess CAFs. The CAFs and coexisting abnormalities were analysed.