Acquired Coronary Fenestration

J INVASIVE CARDIOL 2019;31(12):E396.

Key words: fenestration, iFR, optical coherence tomography

A 74-year-old woman was referred from an outside hospital for shortness of breath and severe aortic stenosis; she was found to be at high risk for surgical aortic valve replacement. Coronary angiography revealed an unusual filling defect in the left circumflex (LCX) artery (Figure 1A) with appearances highly consistent with a lenticular fenestration.

A Prowater guidewire (Asahi Intecc) and a PrimeWire Prestige pressure wire (Volcano Corporation) were placed across the lesion and appeared to course in 2 separate lumens (Figure 1B), consistent with a coronary fenestration. Optical coherence tomography (OCT) revealed a large, eccentric calcific nodule with a thick overlying cap effectively dividing the coronary lumen into 2 channels (Figures 1C and 1D). Distal to the anomaly, instantaneous wave-free ratio (iFR) was severely depressed at 0.44 and iFR pullback showed an abrupt gradient at the site of the lesion (Figure 1E). As both wires converged to the true lumen distally (angiographically) and OCT suggested some persistent anatomical continuity between the 2 lumens at the level of the lesion (Video 1), we elected to proceed with PCI over the pressure wire to permit post-stent hemodynamic assessment. PCI was performed with successful result, including post-stent iFR of 0.92 that improved to 0.99 after postdilation (Figure 1F). The patient underwent an uneventful transcatheter aortic valve replacement 2 days later.

Fenestrations are rare congenital vascular anomalies, predominantly reported in the cerebral circulation, caused by segmental duplication of the intracranial arteries, creating 2 separate and parallel channels, which rejoin distally. There are no prior published reports of such defects in the coronary circulation. Intravascular imaging by OCT in our patient highlights how an angiographic coronary fenestration can be acquired through calcific nodule atherosclerosis in the coronary arteries. We demonstrate how tandem anatomic and physiologic assessment can be used to diagnose, functionally evaluate, and effectively treat this rare finding.

From the ¹Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois; and the ²University of Massachusetts Medical School, Division of Interventional Cardiology, Worcester, Massachusetts.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Kakouros reports personal fees from Edwards Lifesciences, Philips Healthcare, Cardiovascular Systems, Inc, and St. Jude Medical. The remaining authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 15, 2019.

Address for correspondence: Abdul Moiz Hafiz, MD, Division of Cardiology, Southern Illinois University School of Medicine, 701 North 1st Street, P.O. Box 19636, Springfield, IL 62794-9636. Email: ahafiz96@siumed.edu