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DOI:10.2214/AJR.04.1415
AJR 2005; 185:1258-1260
© American Roentgen Ray Society

Case Report

MDCT of Left Anterior Descending Coronary Artery to Main Pulmonary Artery Fistula

Donald S. Chang1,2, Margaret H. Lee2,3, Hsin-Yi Lee2,4 and Bruce M. Barack2,4

1 Division of Cardiology, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd. (111E), Los Angeles, CA 90073.
2 David Geffen School of Medicine at UCLA, Los Angeles, CA.
3 Department of Radiology, Olive View-UCLA Medical Center, Sylmar, CA.
4 Imaging Service, VA Greater Los Angeles Healthcare System, Los Angeles, CA.

Received September 5, 2004; accepted after revision November 10, 2004.

 
Address correspondence to D. S. Chang (dchang{at}ucla.edu).


Introduction
Top
 Introduction
Case Report
 Discussion
 References
 
Most coronary artery fistulas are congenital in origin, but they have been reported to be acquired as complications of chest trauma, coronary angioplasty, and bypass surgery. These fistulas are usually discovered incidentally on coronary angiography or are found at autopsy, because most patients are initially asymptomatic. Some, however, may present with congestive heart failure. Visualization of coronary fistulas has recently been reported using 3D CT in a cadaveric specimen [1]. We present a case of a fistulous communication between the left anterior descending artery and the main pulmonary artery as seen on MDCT in a patient with a medical history of myocardial infarction and percutaneous transluminal coronary angioplasty and a history of penetrating chest injury. Reconstructed images obtained on MDCT are illustrated with correlative angiographic images. To our knowledge, this is the first report of an evaluation of a coronary artery fistula using MDCT in the English-language literature.


Case Report
Top
 Introduction
 Case Report
Discussion
 References
 
A 57-year-old man with a history of coronary artery disease who had undergone percutaneous transluminal coronary angioplasty 15 years earlier and had a history of hypertension, cigarette smoking, and alcohol abuse presented with progressive exertional dyspnea and was found to have congestive heart failure. Other pertinent history included a stab wound to the anterior chest occurring 6 years before angioplasty, which was treated nonsurgically with blood transfusions. At presentation, the transthoracic echocardiogram revealed four-chamber dilation with an ejection fraction of 10% and normal aortic valvular structure and function.

Coronary angiography was performed to evaluate his coronary anatomy and revealed significant disease of the proximal and mid left anterior descending and mid right coronary arteries. In addition, selective angiography of the left coronary system showed a fistula with focal aneurysm arising from the proximal left anterior descending artery before the proximal stenosis and communicating with the main pulmonary artery (Figs. 1A and 1B). Sequential echocardiograms after medical therapy with ß-blocker and angiotensin-converting enzyme inhibitor showed improvement in left ventricular systolic function. An implantable cardioverter defibrillator was placed due to witnessed ventricular fibrillatory arrest.



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  		Fig. 1A —57-year-old man with history of coronary artery disease who was found to have left anterior descending coronary artery to main pulmonary artery fistula with focal aneurysm. Left coronary angiogram in right anterior oblique projection with caudal angulation shows coronary artery fistula (arrow) arising from proximal left anterior descending artery and emptying into main pulmonary artery.

 


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  		Fig. 1B —57-year-old man with history of coronary artery disease who was found to have left anterior descending coronary artery to main pulmonary artery fistula with focal aneurysm. Left coronary angiogram in left anterior oblique projection with caudal angulation shows coronary artery fistula (arrow) arising from proximal left anterior descending artery.

 
As part of the planning for coronary bypass surgery, MDCT was used to further delineate the course of the fistula. After IV administration of nonionic contrast medium, CT coronary angiography was performed on a 16-MDCT unit (Aquilion 16, Toshiba Medical Systems) with a retrospective ECG-gated protocol using a 1-mm section width and a rotation time of 400 msec, a tube voltage of 120 kV, and a tube current of 350 mA. Reconstructed images were then processed by physicians on a separate workstation (Vitrea 2, Vital Images) using standard algorithms available in the CT cardiac package. Three-dimensional volume-rendered images and maximum-intensity-projection images are shown. These images reveal an abnormal fistulous connection with a focal aneurysm between the proximal left anterior descending coronary artery and the main pulmonary artery (Figs. 1C and 1D).



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  		Fig. 1C —57-year-old man with history of coronary artery disease who was found to have left anterior descending coronary artery to main pulmonary artery fistula with focal aneurysm. Three-dimensional volume-rendered CT coronary angiograms show proximal left anterior descending artery to main pulmonary artery fistula (arrow, D).

 


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  		Fig. 1D —57-year-old man with history of coronary artery disease who was found to have left anterior descending coronary artery to main pulmonary artery fistula with focal aneurysm. Three-dimensional volume-rendered CT coronary angiograms show proximal left anterior descending artery to main pulmonary artery fistula (arrow, D).

 

Discussion
Top
 Introduction
 Case Report
 Discussion
References
 
Coronary artery fistulas, defined as abnormal vascular communications between any coronary artery and any of the cardiac chambers or great vessels, are uncommon. True fistulas of the circulatory system are characterized by an ectatic vascular segment that shows aberrant flow connecting two vascular territories governed by large pressure differences [2]. Most are asymptomatic and are discovered as incidental findings at the time of cardiac catheterization and are seen on one of every 500-1,000 coronary angiograms [3].



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  		Fig. 1E —57-year-old man with history of coronary artery disease who was found to have left anterior descending coronary artery to main pulmonary artery fistula with focal aneurysm. E, Maximum-intensity-projection CT image reveals fistula (arrow) from proximal left anterior descending artery.

 
Coronary artery fistulas may be either congenital or acquired in cause. Congenital coronary artery fistulas are commonly associated with obstructive coronary artery disease. The incidence of coronary artery fistula was found to be 0.18% of adult patients undergoing coronary angiography in one large series [3]. Most of the coronary fistulas drain into the right ventricle or pulmonary artery [4]. Even if a patient is initially asymptomatic, it is common for symptoms such as fatigue and dyspnea to develop.

Cardiomyopathy, congestive heart failure, and atrial fibrillation can occur as late findings [5]. Other complications related to coronary fistulas include myocardial ischemia from a steal phenomenon in which competitive flow occurs or from embolization due to thrombus formation within aneurysmal segments, endocarditis, and rupture [6]. Acquired coronary to pulmonary artery fistulas are most often due to complications after coronary artery bypass surgery, particularly when the internal mammary artery is used, or after cardiac transplantation. They may also result from percutaneous coronary interventions. One proposed mechanism of pathogenesis of the acquired coronary to pulmonary artery fistulas is due to neovascularization under the control of specific organizing proteins [2]. The cause of the coronary fistula in our patient is uncertain because it could be congenital or acquired due to his history of percutaneous coronary intervention of the left anterior descending artery and penetrating chest injury.

Clinical signs uncommonly found in an adult patient include a continuous murmur heard along the left sternal border and cardiomegaly with enlargement of the right chambers [7]. Our patient had a holosystolic murmur due to mitral regurgitation as a result of dilated cardiomyopathy and was not known to have a continuous murmur during childhood.

The presence of congenital coronary artery fistulas can be suspected on the basis of transthoracic and transesophageal Doppler echocardiography findings [8] and has been detected on MRI [7]. MDCT was chosen to evaluate the coronary fistula instead of MRI in our patient because of his implantable defibrillator. MDCT is an emerging imaging technique in the evaluation of the cardiovascular system, including the coronary arteries. It is noninvasive and currently has the advantage of time efficiency over MR angiography. Potential applications of CT coronary angiography include identification of anomalous origin and course of the coronary arteries, assessment of patency or occlusion of bypass grafts and coronary artery stents, and evaluation before cardiac surgery.

Indications for fistula closure include myocardial ischemia, large left-to-right shunts, and congestive heart failure [8]. Treatment of coronary artery fistulas has included surgical ligation [9]. The results of surgical closure are generally satisfactory provided that the fistula has a single lumen. More recently, treatment with balloon-expandable polytetrafluoroethylene-covered coronary graft stents and electrolytically detachable platinum coils has been described [6]. Reduction in flow causes the treated vessel to thrombose to the level of the first major branch.

Contrast-enhanced MDCT coronary angiography is a promising noninvasive technique to identify the course of a coronary fistula between the anterior descending artery and main pulmonary artery and is useful in planning the ligation of a fistula at the time of coronary artery revascularization as described in this case.


References
Top
 Introduction
 Case Report
 Discussion
 References
 

  1. Seguchi O, Terashima M, Awano K. Multiple coronary artery fistulas visualized by three dimensional computed tomography. Heart 2003; 89:1381[Free Full Text]
  2. Angelini P. Coronary-to-pulmonary fistulas: what are they? What are their causes? What are their functional consequences? Tex Heart Inst J 2000; 27:327 -329[Medline]
  3. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990; 21:28 -40[Medline]
  4. Gandy KL, Rebeiz AG, Wang A, Jaggers JJ. Left main coronary artery-to-pulmonary artery fistula with severe aneurysmal dilatation. Ann Thorac Surg 2004;77 : 1081-1083[Abstract/Free Full Text]
  5. Perloff JK. Congenital coronary artery fistula. In: Perloff JK, ed. The clinical recognition of congenital heart disease. Philadelphia, PA: Saunders, 1994:562 -580
  6. Goldberg SL, Makkar R, Duckwiler G. New strategies in the percutaneous management of coronary artery fistulas: a case report. Catheter Cardiovasc Interv 2004;61 : 227-232[Medline]
  7. Parga JR, Ikari NM, Bustamante LN, Rochitte CE, de Avila LF, Oliveira SA. Case report: MRI evaluation of congenital coronary artery fistulas. Br J Radiol 2004;77 : 508-511[Abstract/Free Full Text]
  8. Lai MC, Chen WJ, Chiang CW, Ko YL. An unusual case of dual coronary artery fistulas to main pulmonary artery. Chang Gung Med J 2002; 25:51 -55[Medline]
  9. Kamiya H, Yasuda T, Nagamine H, et al. Surgical treatment of congenital coronary artery fistulas: 27 years' experience and a review of the literature. J Cardiol Surg 2002;17 : 173-177

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