IMAGE IN CARDIOLOGY

DOI: 10.4244/EIJV11I6A132

A curly case: dissecting giant arteriovenous anomaly - left main coronary artery shunting to superior vena cava

Maarten de Mulder1,2*, MD, PhD; Tadek R. Hendriksz3, MD; Peter L. de Jong4, MD, PhD; Alexander J.J. IJsselmuiden1, MD, PhD

A 52-year-old female patient with an unremarkable history was admitted to our institution with a non-ST-elevation myocardial infarction (NSTEMI) and underwent coronary angiography (CAG) the following day.

The right coronary artery (RCA) was normal. The left main coronary artery (LMCA) was very large, had a tortuous course and seemed to fistulise to the right atrium (RA). The left anterior descending (LAD) and circumflex (Cx) also originated from this LMCA and had only minor wall irregularities. During the procedure, a dissection emerged proximal in this arteriovenous fistula, large ST elevations appeared, the patient developed ventricular fibrillation and was resuscitated (Figure 1A). As regular coronary stents were too small, the dissection was covered with an Express™ 6.0×18 mm stent (Boston Scientific, Marlborough, MA, USA) provided by the interventional radiologist, after which the patient stabilised. Several days later, the patient was extubated and a coronary CT scan demonstrated that the LMCA anomaly had a maximum diameter of 14 mm and shunts to the superior vena cava (SVC), approximately 3 cm above the RA (Figure 1B). The chest pain at presentation was probably the first symptom of a spontaneous dissection. In the absence of a trigger, the “steal phenomenon” appears less likely. In order to avoid recurrence, on day 12 the patient underwent a thoracotomy where the fistula was closed (Figure 1C). Thirty-four days after initial admission the patient was discharged in a good condition.

Figure 1. Visualisation of the arteriovenous anomaly. A) Angiogram demonstrating the arteriovenous fistula with blushing of contrast into the superior vena cava and right atrium (AVF-RA), catheter into the left main coronary artery with dissection flap (Dis), and left anterior descending (LAD), and circumflex (Cx) coronary artery (Moving image 1). B) CT angiography with the arteriovenous fistula (AVF) with stent (S), superior vena cava (SVC) and aorta (Ao). C) Perioperative view of the aorta (Ao), the arteriovenous fistula (AVF) and superior vena cava (SVC).

Coronary fistulas are rare and may be prone to dissection due to their ectatic course. In this case close cooperation between cardiologist, radiologist and cardiac surgeon was essential.

Conflict of interest statement

The authors have no conflicts of interest to declare.

Supplementary data

Moving image 1. Coronary angiogram demonstrating the arteriovenous fistula with blushing of contrast into the superior vena cava and right atrium, catheter tip into the left main coronary artery with dissection flap, and left anterior descending and circumflex coronary artery.

Supplementary data

To read the full content of this article, please download the PDF.

Moving image 1. Coronary angiogram demonstrating the arteriovenous fistula with blushing of contrast into the superior vena cava and right atrium, catheter tip into the left main coronary artery with dissection flap, and left anterior descending and circumflex coronary artery.

Volume 11 Number 6
Oct 20, 2015
Volume 11 Number 6
View full issue


Key metrics

Suggested by Cory

IMAGE IN CARDIOLOGY

10.4244/EIJ-D-16-00393 Apr 20, 2017
Multiple spontaneous intimal dissections with single left coronary artery and coronary artery aneurysm
Achkouty G et al
free

Image – Interventional flashlight

10.4244/EIJ-D-22-01055 Jul 17, 2023
Aspiration technique in occlusive spontaneous coronary artery dissection
Spînu R et al
free

Image – Interventional flashlight

10.4244/EIJ-D-18-00709 Jan 18, 2019
The fate of spontaneous coronary artery dissection: insight from intravascular imaging at a late follow-up
Amabile N et al
free
Trending articles
57.8

State-of-the-Art

10.4244/EIJ-D-24-00386 Feb 3, 2025
Mechanical circulatory support for complex, high-risk percutaneous coronary intervention
Ferro E et al
free
39.45

Clinical research

10.4244/EIJ-D-23-00725 Nov 19, 2023
A systematic algorithm for large-bore arterial access closure after TAVI: the TAVI-MultiCLOSE study
Rosseel L et al
free
39.45

Original Research

10.4244/EIJ-D-23-00725 Mar 18, 2024
A systematic algorithm for large-bore arterial access closure after TAVI: the TAVI-MultiCLOSE study
Rosseel L et al
free
36.35

State-of-the-Art

10.4244/EIJ-D-23-00448 Jan 15, 2024
Coronary spasm and vasomotor dysfunction as a cause of MINOCA
Yaker ZS et al
free
35.15

State-of-the-Art

10.4244/EIJ-D-23-00895 Apr 1, 2024
Percutaneous interventions for pulmonary embolism
Finocchiaro S et al
free
28.5

CLINICAL RESEARCH

10.4244/EIJV11I1A6 May 19, 2015
European expert consensus on rotational atherectomy
Barbato E et al
free
22.55

CLINICAL RESEARCH

10.4244/EIJV12I5A93 Aug 5, 2016
Longer pre-hospital delays and higher mortality in women with STEMI: the e-MUST Registry
Benamer H et al
free
X

The Official Journal of EuroPCR and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

EuroPCR EAPCI
PCR ESC
Impact factor: 7.6
2023 Journal Citation Reports®
Science Edition (Clarivate Analytics, 2024)
Online ISSN 1969-6213 - Print ISSN 1774-024X
© 2005-2025 Europa Group - All rights reserved