Fistula between a coronary artery bypass graft pseudoaneurysm and the coronary sinus

Abstract

A 73-year-old woman presented with dyspnea on exertion (New York Heart Association [NYHA class II]) without angina, which she had been experiencing for two years. Twenty-three years earlier, the patient had venous conduit coronary artery bypass graft surgery on the left anterior descending artery. Examination revealed normal blood pressure and no heart murmur. The parasternal long-axis view of a routine transthoracic echocardiography (Figure 1) showed marked enlargement of the coronary sinus (23 mm × 48 mm) and mild right chamber dilation. Transcatheter bypass graft angiography (Figure 2) and magnetic resonance angiography (Figure 3) revealed a pseudoaneurysm at the distal portion of the venous conduit bypass graft, with graft occlusion near the distal anastomosis. A slow-flow fistula between the pseudoaneurysm and the dilated coronary sinus was identified. Coronary angiography showed native left anterior descending artery occlusion with perfusion from collateral pathways. No intervention was performed at that time because the patient refused the recommended surgery. Two years later, the patient presented with acute coronary syndrome and a left hemothorax confirmed by pleural fluid analysis. Computed tomography angiography and bypass graft contrast angiography revealed thrombosis of the bypass graft and pseudoaneurysm with no residual fistula and no extravasation. No intervention was performed and the patient had no complaints at the two-month follow-up.

Unusual fistulas and connections in the cardiovascular system: A pictorial review

“…A fistulous communication between a CABG and cardiac vein is extremely rare, with less than 25 cases reported in the literature [18] . It happens more frequently with aortocoronary venous bypass grafts than with arterial grafts.…”

“…It happens more frequently with aortocoronary venous bypass grafts than with arterial grafts. The fistulous communication can occur either in the immediate post-operative period or may manifest after several months or even years [18,19] . This may be asymptomatic or present with heart failure, angina, or continuous precordial murmur.…”