A Spitting-Cobra-Like Coronary-Pulmonary Artery Fistula in a Patient With Angina

Keywords: angina, pulmonary artery fistula, radial access

A 78-year-old woman with a history of hypertension, hyperlipidemia, and asthma was referred to her cardiologist for chest pain and dyspnea on exertion. An electrocardiogram showed biphasic T waves in precordial leads (V1-3). Left and right ventricular systolic function was preserved, without contractile asymmetries and with mild pulmonary hypertension. A stress echocardiography was performed (Bruce protocol). It was finished at 3:36 minutes due to dyspnea and chest pain, with hypokinesis of the anterior wall.

A coronary angiography showed epicardial coronary arteries without significant angiographic stenosis. However, a 2.5-2.75 mm-diameter fistula was observed communicating the proximal portion of the left anterior descending (LAD) coronary to the pulmonary trunk, with an angiographic great debit (Figures 1A, 1B; Video Series). There were also multiple microfistulas to the ventricle (Figure 1A). Given the demonstrated ischemia in the stress test, closure of the fistula with coils was indicated.

We performed right radial access and placed a safety wire on the LAD. A 2.7-Fr x 130-cm Progreat microcatheter system (Terumo Europe NV) was advanced to the medial portion of the fistula. Four Interlock coils (two 2 x 40-mm 2D-Helical coils and two 2-3 x 30-mm Diamond coils; Boston Scientific) were deployed (Figure 1C; Video Series). We observed occlusion of the fistula immediately (Figure 1D; Video Series). After discharge, the patient remained stable, with a clear improvement in her symptoms.

This case highlights that coronary fistula could be an unusual entity of angina, clinically improving after the occlusion procedure.

Affiliations and Disclosures

From the Cardiology Department, Miguel Servet Hospital, Zaragoza, Spain.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The 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 17, 2022.

Address for correspondence: Javier Jimeno Sánchez, MD, Servicio de Cardiología, Hospital Miguel Servet, Paseo Isabel la Católica, 1-3, 50009 Zaragoza, Spain. Email: javierjimeno1@gmail.com