Complex congenital fistula between the coronary, bronchial and pulmonary arteries
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Brief chest pain after plastic surgery. Family history of coronary heart disease. Troponine levels remained slightly above normal. ECG showed no ST elevation.
Tortuous and dilated vessels are demonstrated surrounding and communicating with the pulmonary trunk. There are numerous arterial supplying vessels arising from both the aorta (i.e. neo-bronchial arteries) and the coronary arteries:
- from a supra-aortic vessel (outside FOV)
- from the aortic arch
- from the right coronary sinus, next to the right coronary ostium
- from the proximal right coronary segment
- from the proximal LAD and circumflex artery
- from the descending aorta
Findings are consistent with complex fistula between coronary, bronchial and pulmonary arteries.
This is a case of complex congenital fistula involving the coronary, bronchial and pulmonary arteries.
Reversible chest pain in this case is possibly due to coronary steal phenomenon, which results from left-to-right shunting. There is also a possibility that under certain circumstances the bronchial arteries supply the coronary arteries (left-to-left pattern), or that the pulmonary arteries supply both bronchial and coronary arteries (right-to-left).
As of today, preemptive occlusion of the bronchial arteries with microparticules has been considered way too risky due to the high risk of collateral myocardial infarction. Occlusion of the bronchial arteries with coils could be considered, but there would still have a possibility of inducing the development of preexisting distal coronary to bronchial or pulmonary collateral vessels unseen on this CT. Covered stents in the coronary arteries to separate the coronary network from the bronchopulmonary network might be possible, at the cost of a complex procedure.
Drs Pouillot & Kuhl also contributed to this case. I thank Dr Cochet and Pr Montaudon for their counsel.