Coronary-pulmonary artery fistula diagnosed by multidetector computed tomography

Abstract

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.C oronary-pulmonary artery fistula (CPAF) was first described by Krause in 1865.1 It is a comparatively rare cardiac anomaly, characterised by a communication between a coronary artery having a normal origin from the aorta and a cardiac chamber or a large thoracic vessel such as pulmonary artery and superior vena cava. 2 The clinical presentation of CPAF is highly varied. Most patients, especially those with small fistulas are asymptomatic, and the lesion is discovered during coronary angiography performed for other reasons. Some of the CPAF can result in serious consequences including myocardial ischaemia or infarction, congestive heart failure, and sudden death.3 When complex anatomy or intervention is contemplated, conventional coronary angiography may not be sufficient. An ideal investigation technique should be non-invasive, safe, and provide a quality anatomical description of the fistula. We report a case of a fistula between the left anterior descending artery and the pulmonary artery in an asymptomatic adult subject diagnosed incidentally by multidetector computed tomography. The clinical case, imaging technique, and findings will be discussed. CASE REPORTA 58 year old asymptomatic man with intermediate risk for coronary artery disease was referred by his consultant cardiologist to our department for coronary computed tomography angiography. His physical examination was unremarkable. The electrocardiogram, chest radiograph, and transthoracic echocardiography were within normal limits. ECG gated coronary computed tomography angiography examination was performed using a 16-multidetector computed tomography scanner (1660.625 mm detector collimation, gantry rotation time 0.42 second, tube voltage of 120 kV, and pitch 0,26) (Lightspeed 16 Pro, General Electric Medical Systems).Images of the coronary arteries were reconstructed using curved multiplanar reformats, maximum intensity projection, and 3D volume rendering methods. Cardiac CT images showed a dilated left anterior descending artery coursing along the interventricular groove and terminating abruptly at the mid-interventricular groove, where multiple fine tortuous vessels arise. This vascular plexus formed a network that encircled the LAD and eventually coalesced to form a major dilated vessel that ran horizontally across the anteroinferior aspect of the pulmonary trunk before draining into the pulmonary trunk (figs 1 and 2). A few small vessels of the same ...

Coronary to pulmonary artery fistula: morphologic features at multidetector CT

“…In acquired cases, it is associated with the complications developed after cardiac operation, secondary to endomyocardial biopsy, chest irradiation, chest trauma, percutaneous intervention, and myocardial infarction [9]. However, in our study, such anomalies were not detected, and any procedures causing fistula were not performed in all patients.…”

“…There are several case reports of CPAF diagnosed by MDCT [1,[4][5][6]9]. According to previously reported cases, the variable morphologic features of fistulas were easily identified by using MDCT.…”

“…Factors exerting effects on the manifestation of clinical symptoms and the course are the size of communication, the amount of blood drained through it, the resistance of the recipient chamber, etc. [9]. Presently, accurate imaging data are not available, and it is thought that a large-scale study is required in the future.…”

Bilateral coronary artery fistula and communication between two fistulas identified on multidetector computed tomography in patient with coronary artery disease

“…Levin DC et al reported that approximately 5% of all coronary artery fistulas occur bilaterally [3]. Although coronary angiography remains the main method for imaging the coronary arteries, multidetector row computed tomography (MDCT) scanner is an emerging practical method for the investigation of the relation of coronary artery fistula to the other structures including their origin and course [4,5]. In this paper, we describe a rare case of connection of bilateral coronary artery (left anterior descending coronary artery and right coronary artery) to pulmonary artery with communications between two fistulas and coronary artery disease required PCI with stenting.…”

Unusual fistulas and connections in the cardiovascular system: A pictorial review

“…On CT, demonstration of this fistula requires good contrast opacification of the coronary arteries and non-contrast opacification of the pulmonary artery. Evaluation might be challenging due to low pressure circulation of these fistula causing low blood flow and small caliber of fistula [10,11] . Asymptomatic fistulas are managed conservatively by follow up whereas symptomatic fistulas require surgery or transcatheter closure.…”