From giant fistula to haemodynamic relief: successful percutaneous closure of a symptomatic circumflex coronary artery connection to venous coronary sinus

Background

A coronary artery-to-coronary sinus fistula is a rare anomaly that can cause exertional angina through a coronary steal mechanism.^1,2 We report a successful percutaneous closure of a left circumflex coronary artery (LCX)-to-coronary sinus fistula using covered stents.

Case description

A 69-year-old woman with diabetes, hypertension, and obesity presented with new-onset angina. ECG and echocardiography were unremarkable, but given her cardiovascular risk profile and symptoms, coronary angiography was performed. This revealed normal epicardial coronary arteries and a large fistulous connection between an aneurysmal dominant LCX and the coronary sinus, confirmed by IVUS and cardiac CT (Figure 1). After discussion with Heart-Team, percutaneous closure was selected. Two overlapping covered stents were deployed from the posterior interventricular artery into the distal LCX to accommodate the diameter mismatch between the non-aneurysmal distal segment and the aneurysmal proximal segment, thereby sealing the fistula.

Figure 1.

This panel showcases a rare case of coronary artery-to-venous fistula assessed and treated through a multimodal imaging approach. The structure marked with ‘+’ correspond to left main; ‘X’ corresponds to the circumflex artery, which continues into a small-calibre posterior interventricular branch ‘&’; ‘#’ identifies the obtuse marginal of circumflex artery; and ‘*’ identifies the coronary venous sinus, which serves as the drainage site of the fistula (red arrow). (A and B) Invasive coronary angiography demonstrates a fistulous communication (red arrows) arising from the distal circumflex artery and draining into the coronary venous system. (C and D) Post-intervention angiographic views following percutaneous closure with stent implantation, confirming successful exclusion of the fistulous tract. Red and yellow dotted lines represent the stent implanted respect to the coronary and fistula (3.0 × 18 mm red dotted line and 5.0 × 18 mm yellow dotted line). (E) High-resolution 3D CT reconstruction. (F and G) Intravascular ultrasound (IVUS) with longitudinal reconstructions. (F) shows pre-interventional imaging at the level of the fistula. (G) shows the post-stenting appearance, with successful lumen remodelling and exclusion of the abnormal communication.

The procedure was uneventful, and intravenous tirofiban was administered for 12 h. The patient was discharged on dual antiplatelet therapy and remained asymptomatic for 3 months.

Management of coronary fistulas may be surgical or percutaneous, depending on their morphology, location, and the coronary branches at risk of occlusion following fistula exclusion. Surgery typically involves ligation. Percutaneous options include coils or plugs delivered via venous or arterial access, or exclusion of the fistulous tract with covered stents, as in this case.³ The short length of the fistula precluded coil or vascular plug use, whereas the favourable diameter compatibility of the proximal and distal LCX segments relative to the fistulous portion allowed effective stent implantation.

Conclusion

This case illustrates the feasibility of percutaneous closure of a complex coronary artery fistula, supported by comprehensive multimodality imaging, as a less invasive alternative to surgery.

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports online.

Consent: The patient provided written informed consent for the publication of this case and its associated images.

Funding

This work was partially supported in part by Ricerca Corrente 2025/2026 (ministry of Health), Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico (to S.C.).

Data availability

Data available on request. The data underlying this article will be shared on reasonable request to the corresponding author.