Original Research
Cardiopulmonary Imaging
August 22, 2014

Prevalence and Types of Coronary Artery Fistulas Detected With Coronary CT Angiography

Abstract

OBJECTIVE. The prevalence of coronary artery fistula (CAF) based on coronary angiographic findings has been reported. However, the number of incidentally found CAFs is increasing as coronary CT angiography (CTA) has become popular. The purpose of this study was to determine the prevalence and types of CAFs detected with coronary CTA.
MATERIALS AND METHODS. Between March 2009 and November 2011, 6341 patients underwent coronary CTA at one institution. The prevalence of CAF was retrospectively evaluated, and the morphologic features were analyzed, including vessel of origin, drainage site, size, and presence of an aneurysmal sac. We also analyzed cardiac and pulmonary findings.
RESULTS. Among 6341 patients, 56 (0.9%) patients had CAF. The types of CAF detected, in decreasing frequency, were coronary to pulmonary artery fistula (43 cases [76.8%]), coronary to bronchial artery fistula (five cases [8.9%]), coronary artery to cardiac chamber fistula (five cases [8.9%]), combined coronary to pulmonary and coronary to bronchial artery fistula (two cases [3.6%]), and coronary artery to superior vena cava fistula (one case [1.8%]). Lung parenchymal or vascular anomaly was more frequently noted in coronary to bronchial artery fistulas, combined coronary to pulmonary and coronary to bronchial artery fistulas, and coronary artery to superior vena cava fistulas than in coronary to pulmonary artery and coronary artery to cardiac chamber fistulas.
CONCLUSION. The prevalence of CAF at coronary CTA was 0.9%, which is higher than the known prevalence based on conventional angiographic findings (0.05–0.25%). Furthermore, the most common type of CAF in this study was coronary to pulmonary artery, whereas coronary artery to ventricle fistula was previously considered the most common type in studies conducted with conventional angiography. Coronary CTA is a useful, noninvasive imaging modality for the detection of CAF.
Coronary artery fistulas (CAFs) are unusual coronary anomalies in which abnormal communication between the coronary artery and the cardiac chamber or the great vessels occurs. They are usually congenital, but acquired forms have been reported. CAFs are present in 0.05–0.25% of patients who undergo coronary angiography (CAG) for varying reasons [13]. The most common drainage sites detected with CAG, in decreasing frequency, are the right ventricle, right atrium, pulmonary artery, coronary sinus, left atrium, left ventricle, and superior vena cava (SVC) [4]. However, in addition to problems associated with invasiveness, the complex configuration of the anomalous vessels and their anatomic relations with the adjacent structures may be obscured on 2D fluoroscopic images. Furthermore, the technical difficulty that accompanies cannulation of all of the vessels associated with the CAF may limit precise evaluation of the prevalence of CAFs.
With the rise in the use of coronary CT angiography (CTA), the number of incidentally found CAFs has increased. The use of coronary CTA has led to discrepancies between the reported prevalence of CAF detected with CAG and coronary CTA and to differences in what has been considered the most common drainage site. Given that in coronary CTA, 3D images are constructed that enable easier and more precise access to the vasculature, the prevalence of CAF determined with coronary CTA may be closer to the true incidence of CAF. In this study we aimed to evaluate the prevalence and types of CAF in patients undergoing coronary CTA at our institution.

Materials and Methods

Patients

The institutional review board approved this study, and the requirement for informed consent was waived because of the retrospective design. A total of 6341 patients (3461 men; 2880 women; mean age, 59 ± 11.6 years; age range, 18–90 years) who underwent ECG-gated coronary CTA at our institution between March 2009 and November 2011 were included. We retrospectively reviewed coronary CTA reports by using an electronic database and found the records of 56 patients who had the diagnosis of CAF.

CT Protocols

All patients were examined with a dual-source CT system (Somatom Definition, Siemens Healthcare). For coronary CTA, each patient was given an injection of 80 mL of iopromide (Ultravist 370, 370 mg I/mL, Bayer Schering Pharma; or Iomeron 350, 350 mg I/mL, Bracco) at a flow rate of 5 mL/s followed by a 50-mL injection containing a mixture of contrast medium (15%) and saline solution (85%). Administration of the contrast material was controlled by bolus tracking in the ascending aorta (signal attenuation threshold, 120 HU). The scan delay was 9 seconds, and the scan parameters were slice collimation, 2 × 32 × 0.6 mm with a z-flying focal spot; gantry rotation time, 330 ms; pitch, 0.2–0.5; tube voltage, 100–120 kVp; tube current, 320 mAs. Retrospective ECG gating and ECG-dependent tube current modulation were used. For eight patients, prospective ECG gating was performed with the same parameters, and ECG-triggered image acquisition started at 60% of the R-R interval. The scanning range was from the level of the tracheal bifurcation to the level of the inferior margin of the heart for routine coronary CTA and from the level of the clavicle to the level of inferior margin of the heart for patients who had undergone coronary artery bypass grafts. If a patient's heart rate exceeded 80 beats/min, the heart rate was controlled with the IV selective β1-blocker esmolol (Brevibloc, Jeil Pharma).
All patient imaging data were transferred to workstations (Advantage Windows Workstation, version 4.3, GE Healthcare; Syngo Multimodality Workplace, version 2008, Siemens Healthcare) for review by two radiologists who had 8 years and 1 year of experience in cardiac imaging. A CAF was defined as an abnormal communication between a coronary artery and a cardiac chamber or between a coronary artery and an extracoronary vessel, bypassing the myocardial capillary bed. The evaluation of CAF was made in consensus by joint reading.
We evaluated the characteristics of the CAFs on axial, reformatted, and volume-rendered images. The characteristics assessed included the vessels of origin, the drainage vessels, the presence of an aneurysm (defined as dilatation 1.5 times the diameter of adjacent vessels), combined congenital or acquired anomalies, and the relations with the adjacent structures. Clinical examinations and standard 12-lead ECGs were undertaken for all of the patients with CAFs, and CAG was performed on 14 patients with CAFs. CAG was performed when patients had findings suspicious for coronary artery disease (n = 9) or had large aneurysmal dilatation of a CAF (n = 5).

Results

CAFs were diagnosed with coronary CTA in 56 of 6341 (0.9%) patients (29 men, 27 women; mean age, 60 years; age range, 26–84 years). Patients undergoing coronary CTA most frequently presented with chest pain (n = 35 [62.5%]); other patients had palpitations (n = 4 [7.1%]), dyspnea (n = 2 [3.6%]), and syncope (n = 2 [3.6%]) or were undergoing follow-up after percutaneous coronary intervention (n = 3 [5.4%]) or coronary artery bypass graft (n = 3 [5.4%]). Table 1 summarizes the indications for coronary CTA in this study.
TABLE 1: Indications for Coronary CT Angiography
IndicationNo. of Cases%
Chest pain3562.5
Palpitations47.1
Percutaneous coronary intervention follow-up35.4
Coronary artery bypass graft follow-up35.4
Dyspnea23.6
Syncope23.6
Mitral valve replacement follow-up11.8
Sjögren syndrome with familial history of myocardial infarction11.8
Cardiovascular evaluation because of diabetes mellitus11.8
Cardiovascular evaluation before renal artery aneurysm operation11.8
General health workup11.8
Dizziness with abnormal ECG results11.8
Vasculitis suspected with recurrent right retinal vein occlusion11.8
The CAFs detected were coronary to pulmonary artery fistula in 43 cases (76.8%), coronary to bronchial artery fistula in five cases (8.9%), coronary artery to cardiac chamber fistula in five cases (8.9%), combined coronary to pulmonary and coronary to bronchial artery fistula in two cases (3.6%), and a coronary artery to SVC fistula in one case (1.8%).
Fifteen patients had coronary artery disease: six had one-vessel disease; four had two-vessel disease; and five had three-vessel disease. Six of the 56 patients with a CAF had lung parenchymal abnormalities such as bronchiectasis or hypoplasia of the pulmonary vasculature that could have affected acquired CAF formation. Abnormalities in the lung parenchyma or pulmonary vasculature were more frequent with coronary to bronchial artery (3/5 [60%]), combined coronary to pulmonary and coronary to bronchial artery (1/2 [50%]), and coronary artery to SVC (1/1 [100%]) fistulas than with coronary to pulmonary artery fistulas (1/43 [2.3%]). The Fisher exact test results showed statistically significant differences between coronary to pulmonary artery fistulas and other fistulas with respect to abnormalities in the lung parenchyma or pulmonary vasculature (p < 0.01). No lung abnormalities were apparent in the presence of coronary artery to cardiac chamber fistulas. The abnormalities are summarized according to fistula type in Table 2.
TABLE 2: Presence of Lung Abnormalities in Patients with Coronary Artery Fistula
Fistula TypeNo. of PatientsType of Lung Abnormality
Coronary to pulmonary artery1/43 (2.3)Bronchiectasis
Coronary to bronchial artery3/5 (60)One case each of hypoplasia of right pulmonary artery in Takayasu arteritis, hypoplasia of right pulmonary artery and right inferior pulmonary vein, and bronchiectasis
Coronary artery to cardiac chamber0/5 (0)None
Combined coronary to pulmonary and coronary to bronchial artery1/2 (50)Hypoplasia of right inferior pulmonary artery and right inferior pulmonary vein
Coronary artery to superior vena cava1/1 (100)Bronchiectasis

Note—Values in parentheses are percentages.

Three patients who had a coronary to pulmonary artery fistula underwent surgical ligation because of the presence of large shunts suspected of inducing chest pain. The other 53 patients underwent follow-up by clinical observation.

Coronary to Pulmonary Artery Fistulas

Of the cases in which coronary to pulmonary artery fistulas were detected (43/56 [76.8%]), 18 fistulas (18/43 [41.9%]) originated from the left coronary artery, one (1/43 [2.3%]) from the right coronary artery (RCA), and 24 (24/43 [55.8%]) from both coronary arteries. Among the 18 coronary to pulmonary artery fistulas that originated from the left coronary artery, 16 were from the left anterior descending artery (LAD), and two were from the left main coronary artery. One coronary to pulmonary artery fistula from the RCA originated from the right conal branch of the proximal RCA. Among the 24 coronary to pulmonary artery fistulas originating from both coronary arteries, 10 originated from the LAD and a separately branching conal artery of the right coronary sinus, 12 from the LAD and the proximal RCA (Fig. 1), one from the left main artery and the proximal RCA, and one from the ramus intermedius branch and the proximal RCA.
Fig. 1A —59-year-old woman with coronary to pulmonary artery fistula.
A, Axial coronary CT angiographic images show fistula track between proximal left anterior descending artery (arrowhead, A) and left lateral aspect of main pulmonary artery and aneurysmal dilatation (arrow, B) before track enters main pulmonary artery.
Fig. 1B —59-year-old woman with coronary to pulmonary artery fistula.
B, Axial coronary CT angiographic images show fistula track between proximal left anterior descending artery (arrowhead, A) and left lateral aspect of main pulmonary artery and aneurysmal dilatation (arrow, B) before track enters main pulmonary artery.
Fig. 1C —59-year-old woman with coronary to pulmonary artery fistula.
C, Volume-rendered image shows vascular connection between right coronary artery and pulmonary artery (black arrow), suggesting fistula originates from both coronary arteries. Aneurysmal dilatation (white arrow) is clearly visible.
In most cases (38/43 [88.4%]) the drainage site was the left lateral aspect of the pulmonary trunk (Fig. 1). In five patients (5/43 [11.6%]), the drainage site was the anterior aspect of pulmonary trunk. The high-density flow jet was clearly visible at CT, particularly in patients with an aneurysmal sac or with a large diameter of the fistula vessel, in whom the drainage site could be assessed readily.
In 15 patients (15/43 [34.9%]), the coronary to pulmonary artery fistula was associated with focal aneurysmal dilatation (Fig. 1). One patient had two aneurysm sites, and the other 14 had a single aneurysm. The number of aneurysms and the diameter of both supplying and drainage vessels by fistula type are summarized in Table 3. Nine patients subsequently underwent conventional CAG, which revealed identical origins to those determined with CT.
TABLE 3: Number of Aneurysms and Diameter of Supplying and Draining Vessels by Fistula Type (n = 56)
Fistula TypeNo. of PatientsNo. With Aneurysm PresentDiameter of Supplying Vessel (mm)Diameter of Draining Vessel (mm)
Coronary to pulmonary artery43150.9–4.81.1–10.0
Coronary to bronchial artery501.6–3.11.1–2.3
Coronary artery to cardiac chamber500.9–91.2–2.5
Combined coronary to pulmonary and coronary to bronchial artery211.2–3.1Unmeasurable–2.2
Coronary artery to superior vena cava102.21.4

Coronary to Bronchial Artery Fistulas

All five coronary to bronchial artery fistulas originated from the left circumflex artery (LCX) (Fig. 2). The drainage site was the right bronchial artery in two patients (Fig. 2) and the left bronchial artery in two patients. In the other patients, the drainage site was the bronchial network formed by both bronchial arteries. Conventional CAG subsequently performed in two cases revealed findings identical to those at coronary CTA.
Fig. 2A —70-year-old woman with coronary to bronchial artery fistula.
A, Axial coronary CT angiographic image shows vascular network (thin arrow) between left circumflex (LCX) and right bronchial arteries. Diameter of right inferior pulmonary artery (thick arrow) is smaller than that of left inferior pulmonary artery (arrowhead).
Fig. 2B —70-year-old woman with coronary to bronchial artery fistula.
B, Coronary angiogram obtained after A shows fine vascular networks from LCX (arrow).
Fig. 2C —70-year-old woman with coronary to bronchial artery fistula.
C, Coronary CT angiographic image shows stenotic change and small diameter of right inferior pulmonary vein (arrow). This may have caused insufficient blood supply to right lung, resulting in formation of acquired coronary to bronchial artery fistula.
Three of the five patients (60%) had abnormalities in the pulmonary vasculature or lung parenchyma (Table 2). One patient who had already been found to have Takayasu arteritis had hypoplasia of the right pulmonary artery, and another patient had hypoplasia of the right pulmonary artery and the right inferior pulmonary vein (Fig. 2). In these two cases, we presumed that the fistulas formed to compensate for the insufficient blood flow to the right lung. The third patient had bronchiectasis, which is associated with the development of coronary to bronchial artery fistula.

Coronary Artery to Cardiac Chamber Fistulas

Five coronary artery to cardiac chamber fistulas were detected. Four of these fistulas (80%) originated from the RCA and one (20%) from the LAD. Of the four cases in which the coronary artery to cardiac chamber fistula originated from the RCA, the drainage site was the left atrium in two cases (Fig. 3) and the left ventricle in two cases. In the case in which the coronary artery to cardiac chamber fistula originated from the LAD, the drainage site was the left ventricle. One case subsequently underwent conventional CAG, which showed findings identical to those at CT.
Fig. 3A —48-year-old man with coronary artery to left atrial fistula.
A, Volume-rendered images show ectatic vascular structure (arrow, A) from right coronary artery (RCA) draining into left atrium (arrowhead, B).
Fig. 3B —48-year-old man with coronary artery to left atrial fistula.
B, Volume-rendered images show ectatic vascular structure (arrow, A) from right coronary artery (RCA) draining into left atrium (arrowhead, B).
Fig. 3C —48-year-old man with coronary artery to left atrial fistula.
C, Conventional angiogram obtained after A and B shows ectatic change of fistula between RCA and left atrium. Jet flow to left atrium (arrowhead) is clearly evident.

Combined Coronary to Pulmonary and Coronary to Bronchial Artery Fistulas

Two combined coronary to pulmonary and coronary to bronchial artery fistulas were detected, each with two arterial origins. In one case, the coronary to pulmonary artery fistula originated from both the LAD and the right conal artery and drained into the pulmonary trunk with aneurysm formation (14 × 7 mm). The combined coronary to bronchial artery fistula in this case originated from the LAD and drained to the right bronchial network. Hypoplastic right inferior pulmonary artery and a right inferior pulmonary vein of small diameter were associated findings (Fig. 4). In the other case, the coronary to pulmonary artery fistula originated from both the RCA and the LCX and drained into the pulmonary trunk. The combined coronary to bronchial artery fistula originated from the LCX and drained into the left bronchial network. In this case, the fine pulmonary and bronchial vascular networks were not large enough to allow measurement of the diameter of the drainage vessel.
Fig. 4A —67-year-old man with combined coronary to pulmonary and coronary to bronchial artery fistula.
A, Coronary CT angiographic image shows aneurysmal dilatation (arrow) of fistula track at left aspect of main pulmonary artery. This fistula track originated from left anterior descending artery (LAD) and separately branching conal artery of right coronary sinus. This represents fistula track between both coronary arteries and pulmonary artery.
Fig. 4B —67-year-old man with combined coronary to pulmonary and coronary to bronchial artery fistula.
B, Coronary CT angiographic image shows another fine vascular network originating from LAD and spreading to hypertrophied left bronchial artery (arrowhead), suggesting presence of fistula track between LAD and left bronchial artery.
Fig. 4C —67-year-old man with combined coronary to pulmonary and coronary to bronchial artery fistula.
C, Volume-rendered image clearly shows coronary to bronchial artery fistula (arrowhead) from LAD at posterior aspect and coronary to pulmonary fistula (arrow) from LAD at anterior aspect.

Coronary Artery to Superior Vena Cava Fistula

One coronary artery to SVC fistula was detected (Fig. 5). The fistula originated from the LCX and drained into the SVC. Pulmonary parenchymal changes (emphysema, fibrosis, and bronchiectasis) were noted in this case. Conventional CAG was subsequently performed and revealed findings identical to those noted at coronary CTA.
Fig. 5A —64-year-old man with coronary artery to caval fistula.
A, Axial coronary CT angiographic image shows fistula track (arrow) draining to superior vena cava.
Fig. 5B —64-year-old man with coronary artery to caval fistula.
B, Volume-rendered image clearly shows coronary to caval fistula (arrow).
Fig. 5C —64-year-old man with coronary artery to caval fistula.
C, Axial CT image in lung window shows underlying diffuse bilateral emphysema, linear fibrosis, and mild bronchiectasis.

Discussion

Our study showed that the prevalence of CAFs determined with coronary CTA is 0.9% and that the most common type of fistula is coronary to pulmonary artery fistula. The prevalence of CAF in our study was higher than the reported prevalence of 0.05–0.25% based on CAG studies [13].
Effler et al. [1] reported 15 cases of CAF among 6000 patients (0.25%) undergoing selective CAG, including a pediatric population. Baltaxe et al. [2] reviewed images from 1000 selective CAG examinations of patients older than 18 years and reported two (0.2%) cases of CAF. Van den Brand et al. [3] reviewed the records of 126,595 patients who underwent CAG, including a pediatric population, and reported 62 (0.05%) cases of CAF. The reason for this discrepancy may be the limitations of CAG: cannulating all of the arteries with fistulous origins is technically difficult, and complex configurations of the anomalous vessels and their anatomic relations with adjacent structures can be obscured on 2D fluoroscopic images [5]. Consequently, the prevalence of CAF may have been underestimated.
Contrary to the findings in the CAG studies, in which the most common drainage site of CAFs was the right ventricle, in our study the pulmonary artery was the most common drainage site. Again, this could be due to the technical limitations of CAG. Drainage to the right ventricle may have been much easier to identify on CAG images than drainage to the pulmonary artery is. The complex anatomy of the latter would have been identified accurately only with coronary CTA.
Coronary CTA, with its capability of showing the complex geometry of coronary artery anatomy on 2D and 3D images, is emerging as a valuable tool in the noninvasive diagnosis of CAF. Multiplanar reformations can accurately show the site of origin and the termination of abnormal blood vessels. Furthermore, volume-rendered images give an excellent overview of the cardiac and vascular anatomy. These advantages of coronary CTA may explain the discrepancy between the results of our study and those of previous studies in which CAG was used and may also explain the increase in the number of incidentally detected CAFs as coronary CTA has become more popular [610].
Yun et al. [11] reported that the prevalence of CAF is 0.725% based on coronary CTA findings. They excluded fistulas with extra-cardiac communication, making their prevalence of CAF lower than the prevalence we found. However, the prevalence they found was also much higher than the previously reported prevalence based on CAG findings.
CAFs are either congenital or acquired. Coronary artery to cardiac chamber fistulas and coronary to pulmonary artery fistulas are examples of congenital CAFs. Congenital fistulous connections between the coronary system and a cardiac chamber appear to represent the persistence of embryonic intertrabecular spaces and sinusoids [12]. The embryologic basis for coronary to pulmonary artery fistulas is explained differently by the Hackensellner involution-persistence hypothesis. This theory proposes that there are six branches of the anterior truncus but that only two branches start in the aortic sinus, persist, and form the coronary artery, whereas the others involute. However, when one of the branches that should involute in the pulmonary sinus persists and connects to the branch from the aortic sinus, a fistula forms [13].
Acquired CAFs are being reported with increasing frequency. It is possible that this increase is due to an incremental increase in the use of intravascular procedures and interventional techniques. Other possible factors include atherosclerosis, Takayasu arteritis, and chest trauma [1418]. We presumed that our case of a coronary to bronchial artery fistula accompanied by Takayasu arteritis was an acquired CAF.
Other types of CAF were identified among our cases, but it was difficult to determine whether they were congenital or acquired. It was evident, however, that abnormalities in the lung parenchyma or in the pulmonary vasculature were more frequent in cases of coronary to bronchial artery fistulas, combined coronary to pulmonary and coronary to bronchial artery fistulas, and coronary artery to SVC fistulas compared with other CAFs (Table 2). This finding may support the hypothesis that abnormalities in the lung parenchyma or pulmonary vasculature may induce several types of acquired forms of CAF.
The treatment of patients with CAFs depends on the size and anatomic features of the fistula, the presence of symptoms, the patient's age, and the presence of other cardiovascular diseases. If the patient has symptoms, the fistula is closed by either a surgical or a transcatheter approach [19]. However, fistula closure in patients without symptoms remains controversial. The hemodynamic significance of the fistula is important in determining the treatment of patients without symptoms. Adenosine 99mTc-sestamibi myocardial perfusion SPECT may be useful in determining whether myocardial ischemia is associated with a CAF [20]. Oh et al. [21] suggested using fractional flow reserve measurements to assess the hemodynamics of CAFs. However, precise guidelines for the management of CAF have not been established. Further study is needed to assemble principles for the management of CAF, because the prevalence of CAF in the current study was much higher than we expected.
Of the 56 patients with CAFs in our study, three underwent ligation operations. One of these patients had chest pain and a large aneurysm that measured up to 1.4 cm in diameter. The other two patients underwent adenosine myocardial SPECT. Two of the patients had positive stress test results and focal perfusion defects in the apical region. Because there were no other abnormalities except for the coronary to pulmonary artery fistulas, the perfusion defects at SPECT and the symptoms were considered to be caused by a CAF. The management plans for the other 53 patients were clinical observation and follow-up.
Our study had limitations. First, the study population was too small for estimation of the actual prevalence of CAF in the general population. Second, coronary CTA was performed when a patient presented with particular symptoms or because of clinical need, which may have caused selection bias because patients without symptoms were not included. Third, this study was retrospective in design and lacked clinical and CAG correlation. However, it has been found [22] that MDCT can replace CAG in the diagnosis of anomalous coronary arteries and has high sensitivity (100%) in the visualization of normal and abnormal coronary vessels. Fourth, this study was a single-center experience; hence, it is difficult to generalize to other institutions. Our hospital is a tertiary academic hospital and is not specialized in cardiovascular disease. It may be possible, however, to apply the results to hospitals with similar conditions.

Conclusion

Coronary CTA allows detailed delineation of cardiac anatomy and is a useful noninvasive imaging modality for the detection of CAF. The findings in the current study indicate that the prevalence of CAF detected with coronary CTA is 0.9%, which is higher than the known prevalence of 0.05–0.25% detected with CAG. In this study, the most common type of CAF was coronary to pulmonary artery fistula; coronary artery to ventricular fistula had been previously considered the most common type.

Footnote

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FOR YOUR INFORMATION

The reader's attention is directed to a related article, titled “MDCT Imaging of Congenital Coronary Artery Fistulas,” which begins on page W244.

Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: W237 - W243
PubMed: 25148179

History

Submitted: July 17, 2013
Accepted: December 28, 2013

Keywords

  1. coronary artery fistula
  2. coronary CT angiography
  3. prevalence
  4. types

Authors

Affiliations

Jae Jung Lim
Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-Gu, Seoul 137-701, South Korea.
Jung Im Jung
Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-Gu, Seoul 137-701, South Korea.
Bae Young Lee
Department of Radiology, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
Hae Gui Lee
Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-Gu, Seoul 137-701, South Korea.

Notes

Address correspondence to J. I. Jung ([email protected]).

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