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Case Illustration

Giant Coronary Artery Fistula


in Stable Angina Pectoris Patient
RD. Robin H Wibowo

Giant coronary artery stulas are very rare case. Coronary anomalies
are seen in 1.3% of coronary angiograms with 10%13% of these
anomalies are coronary artery stulas.1 Huge coronary artery stulas
are extremely rare, and only a few case reports have been described. 2
Most coronary artery stulas are asymptomatic and are found
incidentally during coronary angiography, cardiac Computed
Tomography (CT) scan, or other imaging modalities. The course of the
disease and the management has not been clearly dened. However,
approximately 20% of these stulas are clinically relevant.1,3

A 57-year-old-man presented with chest pain and dyspnea on


effort for 3 months. He did not describe paroxysmal nocturnal dyspnea
or palpitations, and was not known to have any chronic illnesses.
Physical examination showed a heart rate of 82 beats per minute,
blood pressure of 125/74 mmHg, and normal jugular venous pressure.
Chest auscultation revealed unremarkable result. Her lower limbs
showed no edema. An electrocardiogram revealed normal ndings.

A coronary angiogram showed a dominant right coronary artery


system. An aortic root angiogram revealed the left main and the LAD
to be a giant and tortuous vessel communicating with the sinus
coronarius and eventually drains to the right atrium. For further
delineation of the left main coronary artery anatomy and the exact site
of the stulous communication, coronary computed tomographic
angiography was performed (Figure 1).
Figure 1. Aortography
result

The cardiac CT
result showed a
dominant right
coronary artery. The
right coronary artery and the left main coronary artery originating at
the usual site of valsava sinus. The left main origin is in the left
coronary cusp, the left main became huge and ectatic and divided into
the left anterior descending artery and the left circumflex coronary
artery. The left circumflex artery was huge and very tortuous, twisting
few times before joining and draining into the coronary sinus, which
was also dilated.

Figure 2. Cardiac CT
result

The patient presented with angina pectoris. It is possible that


high flow in the stula resulted in a coronary steal phenomenon with
subsequent ischemia and dysfunction of the left ventricle. Although
arteriovenous stulas are known to cause high-output heart failure, the
patient did not present with heart failure. Given the rarity of such a
condition and the anatomical variation of these stulas, there are no
guidelines developed to aid in the management of such patients.
Therefore the management of this case is vague. In this case, given
the potential risk of rupture of the abnormally dilated vessel, the
presence of angina pectoris, and the signicant left-to-right shunt as
well as left ventricular dysfunction risk, are the decision point to refer
the patient for surgery with the aim of ligating the stula and a
2,4
possible bypass procedure.
A transcatheter approach to coronary artery stula is an
attractive alternative treatment option.5 However, this modality of
treatment might be suitable for smaller and nonaneurysmal coronary
artery stulas. Multiple imaging techniques, including
echocardiography, coronary artery computed tomography and invasive
angiography utilized to delineate the exact anatomy of these tortuous
stulas, were of great help to the surgeon in planning the approach
technique to the stula and minimizing the time of the surgery.

References
1. Yamanaka O and Hobbs RE. Coronary artery anomalies in
126,595 patients undergoing coronary arteriography. Cathet
Cardiovasc Diagn 1990; 21: 2840.
2. Darwazah AK, Eida M, Batrawy M, Isleem I and Hanbali. N.
Surgical treatment of circumflex coronary aneurysm with
stulous connection to coronary sinus associated with persistent
left superior vena cava. J Card Surg 2011; 26: 608612.
3. Yildiz A, Okcun B, Peker T, Arslan C, Olcay A and Bulent Vatan M.
Prevalence of coronary artery anomalies in 12,457 adult patients
who underwent coronary angiography. Clin Cardiol 2010; 33:
E60E64.
4. Hajj-Chahine J, Haddad F, El-Rassi I and Jebara V. Surgical
management of a circumflex aneurysm with stula to the
coronary sinus. Eur J Cardiothorac Surg 2009; 35: 10861088.
5. Kabbani Z, Garcia-Nielsen L, Lozano ML, Febles T,Febles-
Bethencourt L and Castro A. Coil embolizationof coronary artery
stulas. A single-centre experience. Cardiovasc Revasc Med
2008; 9: 1417.
6. Almansori, Mohammed and Tamim, Muhammed. Giant coronary
artery stula. Asian Cardiovascular and Thoracic Annal. 2013

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