A significant ‘coronary steal’ by thebesian veins, a rare congenital coronary defect masquerading as acute coronary syndrome

Abstract

DESCRIPTIONA 72-years-old woman presented with intermittent chest pains, anterolateral T-wave inversions on ECG and troponin-T of 6290 ng/L. Acute coronary syndrome treatment was initiated. The coronary angiography demonstrated tortuous calcified coronaries without any significant obstructive lesion. However, late dye acquisition images revealed a capillary blush originating from the diagonal branch of left anterior descending artery (figures 1 and 2) and the distal right coronary artery (figures 3 and 4) feeding into the ventricular cavity through intramural thebesian vein connections, almost producing a ventriculogram (figures 5 and 6).This episode which otherwise would been an undetectable plaque event, turned out to be one of significant myocardial injury due to background presence of the 'the coronary steal' syndrome.Persistence of embryonic coronary artery fistulas in form of diffuse vascular network directly draining oxygenated blood from the coronaries into the ventricles bypassing the myocardial capillary network are called thebesian veins. Coronary artery fistulas are rare (<0.2% 1 ), remain silent and often discovered incidentally on coronary angiogram or ventriculography.2 They rarely become haemodynamically significant and become a nonatherosclerotic cause of angina via the coronary steal phenomenon. 3Case reports of steal Figure 1 The flow through the coronary artery fistula (thebesian veins) in the diagonal branch of left anterior descending artery is seen (in late dye acquisition images) as a capillary blush (marked with arrows) in the RAO cranial view. This flow is causing drainage of oxygenated blood directly from coronaries into the ventricular cavity. Figure 2 The flow through the coronary artery fistula (thebesian veins) in the diagonal branch of left anterior descending artery is seen (in late dye acquisition images) as a capillary blush (marked with arrows) in the RAO caudal view. This flow is causing drainage of oxygenated blood directly from coronaries into the ventricular cavity. Figure 3 The flow through the coronary artery fistula (thebesian veins) in the distal right coronary artery is seen (in late dye acquisition images) as a capillary blush (marked with arrows) in the LAO view. This flow is causing drainage of oxygenated blood directly from coronaries into the ventricular cavity.

Response by Kim et al. to Letter regarding article, “Prominent Thebesian veins, a rare congenital coronary anomaly presenting as acute myocardial ischemia”

“…Since the initial reports of Wearn et al (1928 and, careful studies about these coronary-cameral connection vessels were not added until Ansari (2001). Since then, based on Ansari's report, microfistulae findings between the coronary arteries and ventricular chambers, which are rarely observed in coronary angiography, have been reported as 'Thebesian veins' in several articles [5,6] and case reports [7][8][9] similar to ours. According to the original paper written by Wearn et al [2] and the explanations of Dr. Snodgrass et al [10], it is erroneous to refer to the link between the coronary artery and ventricular chamber observed in coronary angiography as the Thebesian vein, because Thebesius studied the connection between the coronary sinus and ventricular chamber.…”

Prominent Thebesian veins, a rare congenital coronary anomaly presenting as acute myocardial ischemia

“…In addition, a profound drop in perfusion pressure because of rapid run-off and impaired subendocardial perfusion of the hypertrophied myocardium could also induce myocardial ischemia [5]. Some cases of prominent Thebesian veins present as ischemic heart disease [2,6] and even, acute coronary syndrome [7], but reports demonstrating the imaging evidence of inducible ischemia in these patients are sparse [8]. In this report, we described the subendocardial nature of definite perfusion defect using cardiac MRI in a patient with significant coronary microfistulae through Thebesian veins.…”