Huge Saccular Aneurysm in a Coronary-Pulmonary Fistula Fed by the Left and Right Coronary Arteries.

Abstract

ecause a communication between the coronary arteries and the cardiac chamber or the pulmonary trunk is not a common anomaly, 1 the formation of an aneurysm in this communication vessel is clinically few. [2][3][4] We report an adult case of a huge aneurysm that was fed by both the left anterior descending and the right coronary artery draining anomalously into the main pulmonary artery. Case ReportA 62-year-old woman was referred to hospital because of an abnormal mediastinal shadow on chest roentgenogram. She had been pointed out a heart murmur 30 years ago, but did not have further examinations because she did not have any symptoms. An abnormal shadow on the left cardiac border was first noted on plain chest roentgenogram 4 years ago and since then the size of the mass had gradually increased (Fig 1). However, she did not develop angina-like chest pain on effort.Physical examination revealed a grade 4/6 continuous cardiac murmur at the second intercostal space. Blood pressure was 135/80 mmHg. There was complete right bundle branch block on ECG. Two-dimensional echocardiography revealed a round cystic lesion with internal spontaneous echo contrast, located in contact with the pulmonary trunk (Fig 2). Computed tomography showed a giant mass of 5.8×6.0 cm in diameter into which the left and right coronary arteries drained (Fig 3). During catheterization, oximetry revealed an oxygen step-up of 4% between the pulmonary artery and the right ventricle, consistent with a left-to-right shunt of 3.4%. The pulmonic-to-systemic blood flow ratio (Qp/Qs) was 1.04. Digital subtraction coronary Circulation Journal Vol.66, May 2002 angiography confirmed that each branch of the left anterior descending artery and the right coronary artery drained into the huge aneurysm (Fig 4). However, the efferent vessels into the pulmonary artery were not clearly demonstrated by angiography, but color Doppler flow imaging revealed the small efferent flow was running from the aneurysm to the main pulmonary artery (Fig 5). From these findings, she was diagnosed as having a coronary -pulmonary fistula with a concomitant huge saccular aneurysm that was considered to have progressively enlarged during the preceding 4 years, and surgical resection was proposed.At operation, an egg-shaped, elastic, cardiac tumor 6 cm in diameter was found in front of the right ventricular outflow tract. The afferent vessels were confirmed to arise

Giant aneurysm in a left coronary artery fistula: diagnostic cardiovascular imaging and treatment considerations

“…Approximately 50%, 42% and 5% of CAF arise from the RCA, the LAD and both vessels, respectively. The most common drainage sites are low-pressure structures as: the right ventricle (41%), right atrium (26%), pulmonary artery (17%), coronary sinus (7%), left atrium (5%), left ventricle (3%) and the superior vena cava (1%), respectively 1 2. Most fistulas are single communications, but multiple fistulas and fistulas associated with fusiform or saccular aneurysms have been reported 3.…”

Two cases of giant aneurysm in coronary–pulmonary artery fistula associated with atherosclerotic change

“…There is a previous report of giant aneurysm in coronary -pulmonary fistula with cystic medial change [2]. By contrast, some reported that the wall of saccular aneurysms had calcified change [3 -5].…”

“…Saccular aneurysm in coronary -pulmonary fistula is extremely rare [1][2][3]. There is a previous report of giant aneurysm in coronary -pulmonary fistula with cystic medial change [2].…”

Histopathologic Characteristics of a Coronary-pulmonary Artery Fistula with a Coronary Artery Aneurysm

“…Although a coronary artery aneurysm associated with a fistula may result secondarily from atherosclerotic changes or traumatic injury to the fistula, it is even more rare than coronary artery fistulas. 2,3) The clinicopathologic characteristics of a coronary artery fistula concomitant with a coronary artery aneurysm are poorly understood because of their rarity.…”