Abstract
Objective:
This study aimed to compare and analyze the diagnostic performance of cardiac computed tomographic angiography (CCTA) and transthoracic echocardiography (TTE) for coronary artery fistula (CAF) and evaluate the effectiveness of these two imaging modalities.
Methods:
We retrospectively collected and analyzed imaging data from 200 patients diagnosed with CAF through surgery or digital subtraction angiography (DSA). These patients underwent CCTA and TTE examinations in our hospital. Finally, the course, origin, number, size, and location of the CAF in all patients were assessed. The diagnostic results of CCTA were compared with those of TTE, using DSA and/or surgical diagnosis as the reference standard.
Results:
Among the 200 patients with CAF, CCTA correctly diagnosed 156 cases, but missed 44 cases, resulting in a diagnostic accuracy of 78.0% (156/200). In contrast, TTE accurately diagnosed 55 cases, but missed 145 cases, yielding a diagnostic accuracy of 27.5% (55/200). The diagnostic accuracy of CCTA was significantly higher than that of TTE in detecting CAF (P < 0.001).
Conclusion:
CCTA demonstrated significantly greater diagnostic value than TTE, demonstrating to be the preferred imaging modality for diagnosing CAF.
Keywords: Cardiac computed tomographic angiography (CCTA), Coronary artery fistula (CAF), Imaging diagnosis, Transthoracic echocardiography (TTE), Vascular anomaly, Digital subtraction
1. INTRODUCTION
Coronary artery fistula (CAF) is a rare vascular anomaly in clinical practice (with an incidence rate of 0.5% or even lower) [1, 2]. It is characterized by an abnormal connection between the coronary artery trunk or its branches and the cardiac chambers or major blood vessels [3-6]. The clinical presentation of CAF lacks specificity, and some patients may present with symptoms, such as dyspnea, chest pain, and palpitations. In more severe cases, CAF can significantly impair myocardial perfusion, potentially resulting in myocardial ischemia or even sudden death [7, 8]. Therefore, early and accurate diagnosis of CAF is crucial.
There are multiple imaging methods available for the clinical diagnosis of CAF, including digital subtraction angiography (DSA), cardiac computed tomographic angiography (CCTA), transthoracic echocardiography (TTE), and magnetic resonance coronary angiography (MRCA). DSA, regarded as the “gold standard”, enables direct visualization of coronary artery anatomy, the morphology of the coronary artery and its branches, as well as the connections with cardiac chambers or blood vessels. However, this method is invasive and entails the risk of complications and high radiation exposure [9, 10]. MRCA offers advantages, such as multiparametric, multisequence, and multiplanar imaging, along with being radiation-free. However, this approach is constrained by relatively slow image acquisition, susceptibility to motion artifacts induced by breathing and cardiac motion, and inadequate visualization of small and tortuous fistulae, thereby restricting its clinical application [11-14]. In recent years, CCTA has gained widespread clinical use due to its high temporal and spatial resolution, low radiation dose, and good image quality. It offers a noninvasive option for assessing coronary artery lesions and providing preoperative planning for cardiac interventions. Additionally, with advancements in ultrasound technology, TTE has become another non-invasive diagnostic method for identifying CAF. TTE not only provides detailed real-time dynamic visualization of CAF blood flow, but also offers strong repeatability, no radiation exposure, and lower cost.
Therefore, the non-invasive examination methods for clinical diagnosis of CAF are mainly CCTA and TTE. Although two studies have explored the diagnostic performance of CCTA and TTE for CAF, there have been differences in the research results, and the sample sizes have not been more than 60 cases [15, 16]. Given that CAF is a rare vascular abnormality and large-sample imaging studies are currently scarce, this study collected data from 200 CAF patients diagnosed by surgery or DSA. The aim was to compare and analyze the imaging diagnostic results of CCTA and TTE, and explore the diagnostic efficacy of these two methods in identifying CAF.
2. MATERIALS AND METHODS
2.1. Patient Population
Patients who were diagnosed with CAF and admitted to the Asia Heart Hospital from January 2016 to November 2021 were retrospectively analyzed in this study. The study flowchart is shown in Fig. (1). The inclusion criteria for patients were as follows: 1) the diagnosis confirmed by surgery and/or DSA; 2) undertaken both CCTA and TTE examinations at our hospital within three months; 3) availability of complete and comprehensive clinical case data and imaging results. The exclusion criteria were as follows: 1) the diagnosis not confirmed by surgery and/or DSA; 2) only one type of examination (either CCTA or TTE) undertaken within three months; 3) incomplete or poor-quality imaging information obtained for both CCTA and TTE examinations. This study was approved by the ethics committee of the Asia Heart Hospital (ethics no. 2022-13031) and all patients signed an informed consent form.
Fig. (1).
Flowchart of the inclusion and exclusion criteria. Note: CAF, coronary artery fistula; CCTA, cardiac computed tomographic angiography; DSA, digital subtraction angiography; TTE, transthoracic echocardiography.
2.2. CCTA Examination Method
Before scanning, patients were provided with respiratory training and instructed to place nitroglycerin tablets under their tongues. A Brilliance iCT scanner (Netherlands, Philips) or a Somatom Definition FLASH CT scanner (Siemens, Germany) was used, with electrocardiogram gating and intelligent tracking triggering scan technology. The region of interest (ROI) was set at the root of the aorta, and the scanning commenced when the aortic CT value reached 120-140 Hounsfield units (HU). The scan covered the area from the tracheal bifurcation to 2 cm below the cardiac diaphragm. The scanning parameters of the two devices were identical: a tube voltage of 100-140 kV, intelligent milliampere-seconds (mAs) for dose modulation, a pitch automatically adjusted based on heart rate, a slice thickness of 0.60-0.75 mm, an interlayer spacing of 0.3-0.4 mm, and a matrix of 512×512. After the examination, the best diastolic and systolic coronary artery images were reconstructed and uploaded to the Picture Archiving and Communication System (PACS) and postprocessing workstation.
2.3. TTE Examination Method
The patients were positioned either in the supine or in the left lateral position during the examination. A color Doppler ultrasound diagnostic instrument (Aloka Prosound F75, Hitachi, Japan) was used to continuously observe and assess the presence of coronary artery dilation, tortuosity, and abnormal blood flow signals within the cardiac chambers and major vessels; the origin, morphology, and course of the fistula; as well as the location, size, and number of feeding vessels in the fistula.
2.4. Imaging Evaluation
Two experienced cardiovascular imaging specialists from the radiology department and two from the ultrasound department independently diagnosed and evaluated the course, origin, number, size, and location of the CAF in all patients. If there was a disagreement between the two doctors within their respective departments, the assessment was reviewed by senior professionals in their field to reach a consensus. The diagnostic results of each department were then obtained. Finally, taking DSA and/or surgical diagnosis as the reference standard, the diagnostic results of CCTA were compared with those of TTE.
2.5. Statistical Analysis
The obtained data were analysed using the statistical software SPSS (Version 26.0, IBM America GmbH, USA), and a chi-square test was conducted to evaluate the diagnostic accuracy of the two imaging methods. The diagnostic accuracy was estimated as follows: (the number of detected cases/the total number of cases)×100%. The continuous data have been presented as mean ± SD. The count data were expressed as the number or number (percentage), namely n or n (%). P<0.001 indicated statistical significance.
3. RESULTS
3.1. General Information
A total of 798 patients with clinically suspected CAF were screened in the hospital's case management system. Based on the inclusion and exclusion criteria, 200 patients (100 males and 100 females; age range: 0.08-81 years; mean age: 49.68±23.14 years) with CAF were ultimately included. The clinical characteristics of all patients with CAF are shown in Table 1.
Table 1.
Clinical characteristics of 200 patients with CAF.
| Clinical Characteristics | n (%) |
|---|---|
| Sex | |
| Male | 100 (50.0) |
| Female | 100 (50.0) |
| Mean age (years) | 49.68±23.14 |
| Age range (years) | 0.08-81 |
| Age Groups | |
| 0-9 years | 28 (14.0) |
| 10-24 years | 6 (3.0) |
| 25-49 years | 25 (12.5) |
| 50-74 years | 127 (63.5) |
| ≥75 years | 14 (7.0) |
| BMI (kg/m2) | 23.28±4.90 |
| Complications | |
| Hypertension | 74 (37.0) |
| Diabetes mellitus | 21 (10.5) |
| Dyslipidemia | 31 (15.5) |
| Previous MI | 10 (0.5) |
| Known CHD | 127 (63.5) |
| Arrhythmia | 55 (27.5) |
| Other congenital cardiac malformations | 19 (9.5) |
| Clinical Symptoms | |
| Asymptomatic | 57 (28.5) |
| Symptomatic* | 143 (71.5) |
| Treatments | |
| Transcatheter interventional | 50 (25.0) |
| Surgery | 77 (38.5) |
| Conservative treatment | 73 (36.5) |
BMI, body mass index; MI, myocardial infarction; CHD, coronary heart disease. *Symptoms included dyspnea, thoracalgia, oppression in the chest, chest tightness, and palpitation.
3.2. DSA and/or Surgery Results
Among the 200 patients with CAF, 1) 65 patients were diagnosed via surgical procedures. Among them, 64 patients underwent surgical closure, and only 1 patient incidentally discovered the CAF during surgery for another cardiac condition, but did not receive treatment due to the small size of the fistula. 2) 135 patients were diagnosed with CAF through DSA. Among these patients, 50 patients underwent transcatheter closure, 13 patients underwent surgical closure for concomitant other cardiac conditions after the CAF was identified through DSA, and 72 patients did not undergo surgical treatment. Therefore, 50 (25.0%) patients underwent transcatheter closure, 77 (38.5%) patients underwent surgical closure, and 73 (36.5%) patients did not receive treatment.
3.3. Classification of CAFs
As shown in Table 2, 1) classification based on origin included 73 patients (36.5%) having left CAF, 59 patients (29.5%) having right CAF, and 68 patients (34%) having both left and right CAF. 2) Classification based on drainage site included 126 patients (63%) having coronary artery-pulmonary artery fistulas, 44 patients (22.0%) having coronary artery-ventricle fistulas, 24 patients (12%) having coronary artery-atrium fistulas, 3 patients (1.5%) having coronary artery-coronary sinus fistulas, 2 patients (1%) having coronary artery-bronchial artery fistulas, and 1 patient (0.5%) having both coronary artery and bronchial artery-pulmonary artery fistulas. 3) Classification based on fistula size included 50 patients (25.0%) having small fistulas, 87 patients (43.5%) having medium fistulas, and 63 patients (31.5%) having large fistulas. 4) Classification based on blood shunt direction included 174 patients (87.0%) having left-to-right shunting and 26 patients (13.0%) having left-to-left shunting.
Table 2.
The diagnostic results of CCTA and TTE in different CAFs (200 cases).
| CAF Categories | Total (cases) | CCTA | TTE | ||||
|---|---|---|---|---|---|---|---|
| Detected (cases) | Undetected (cases) | Inaccurate localization in Origin/drainage Site (cases) | Detected (cases) | Undetected (cases) | Inaccurate Localization in Origin/drainage Site (cases) | ||
| Origin | |||||||
| LCA | 73 | 50 | 23 | 1 | 15 | 58 | 5 |
| RCA | 59 | 48 | 11 | 1 | 31 | 28 | 1 |
| LCA and RCA | 68 | 58 | 10 | 10 | 9 | 59 | 7 |
| Drainage site | |||||||
| PA | 127 | 96 | 31 | 11 | 13 | 114 | 11 |
| RA | 20 | 16 | 4 | 0 | 14 | 6 | 1 |
| RV | 24 | 22 | 2 | 0 | 18 | 6 | 0 |
| LA | 4 | 2 | 2 | 0 | 1 | 3 | 0 |
| LV | 20 | 17 | 3 | 1 | 7 | 13 | 1 |
| CS | 3 | 3 | 0 | 0 | 2 | 1 | 0 |
| BA | 2 | 0 | 2 | 0 | 0 | 2 | 0 |
| Fistula diameter(D:mm) | |||||||
| Small(D≤2) | 50 | 32 | 18 | 1 | 7 | 43 | 2 |
| Medium(2<D≤4) | 87 | 68 | 19 | 8 | 18 | 69 | 6 |
| Large(D>4) | 63 | 56 | 7 | 3 | 30 | 33 | 5 |
| Shunt direction | |||||||
| Left to right | 174 | 137 | 37 | 11 | 47 | 127 | 12 |
| Left to left | 26 | 19 | 7 | 1 | 8 | 18 | 1 |
LCA: left coronary artery, RCA: right coronary artery, PA: pulmonary artery, RA: right atrium, RV: right ventricle, LA: left atrium, LV: left ventricle, CS: coronary sinus, BA: bronchial artery.
3.4. Comparison of the Diagnostic Results
Among the 200 patients with CAF, CCTA accurately diagnosed 156 cases, but missed 44 cases, exhibiting a diagnostic accuracy of 78.0% (156/200). Of these accurately diagnosed cases, 144 patients had accurate diagnoses of both the origin and drainage site, while in 12 patients, the origin or drainage site of the fistula could not be determined. In contrast, TTE correctly diagnosed 55 cases, but missed 145 cases, resulting in an accuracy of 27.5% (55/200). Within this group, 42 patients had accurate diagnoses of both the origin and drainage site, while in 13 patients, the origin or drainage site of the fistula could not be determined. There was a significant difference in the accuracy of CAF diagnosis between the two imaging methods (P<0.001) (Table 3 and Figs. 2 and 3). Furthermore, both CCTA and TTE had higher diagnostic accuracy for large fistulas than for small-to-medium-sized fistulas, with small-to-medium-sized fistulas being more prone to missed diagnoses (Table 2).
Table 3.
The diagnostic accuracy of CCTA and TTE.
| Imaging Methods | Detected (cases) | Undetected (cases) | Diagnostic accuracy | χ 2-value | P-value |
|---|---|---|---|---|---|
| CCTA | 156 | 44 | 78.0% | 101.00 | <0.001 |
| TTE | 55 | 145 | 27.5% |
The diagnostic accuracy was estimated as follows: (the number of detected cases/the total number of cases)×100%.
Fig. (2).
A case of right coronary artery-to-right atrium fistula. Both CCTA and TTE accurately diagnosed the patient’s condition and identified the origin and drainage site of the fistula. The CCTA images visually and accurately illustrate the dilated right coronary artery (a, blue arrow), the arterial aneurysm (b and c, white arrows), and the fistula draining into the right atrium with the “ejection sign” (d, red arrow). TTE demonstrates the widening of the right coronary artery at its origin (e, blue arrow) and abnormal blood flow into the right atrium (f, red arrow). a-c, CCTA volume-rendering (VR) images. d, CCTA maximum intensity projection (MIP) image. e-f, TTE two-dimensional images. Note: AO, aorta; RCA, right coronary artery; RA, right atrium.
Fig. (3).
A case of right coronary artery-to-right atrium fistula. CCTA accurately confirmed the existence of this fistula, while TTE identified the fusiform dilation in the proximal part of the right coronary artery, but it was unable to clearly define the course or the final drainage site of the dilated artery. The CCTA image visually and accurately depicts the dilated and tortuous course of the right coronary artery (a and c, blue arrows), the arterial aneurysm (c, white arrow), and the fistula draining into the right atrium (b, red arrow). TTE shows the right coronary artery with widening at the origin (d and e, blue arrows), a downward course, and overall dilatation within the explored range. a, The CCTA MIP image. b, CCTA multiplanar reformation (MPR) image. c, CCTA VR image. d-f, TTE two-dimensional images. Note: AO: aorta; RCA: right coronary artery; RA: right atrium; RV: right ventricle; LA: left atrium; LV: left ventricle.
4. DISCUSSION
In this study, the accuracy rate of CCTA was 78.0%, while that of TTE was relatively lower, being 27.5%. The results indicated the diagnostic efficacy of CCTA in identifying CAF to be significantly higher than that of TTE.
TTE presents several advantages, including noninvasiveness, convenience, affordability, real-time dynamic observation, and strong repeatability. Color Doppler ultrasound can reveal the origin and drainage site of the CAF, as well as the diameter of the fistula, the size of the shunt, and the blood flow velocity. This renders it a valuable tool for the preoperative detection, intraoperative exploration, and postoperative follow-up of CAF [17]. TTE is also capable of revealing various related congenital and acquired cardiac defects [18]. However, this technique is significantly affected by patient body size, possesses limited acoustic windows, is highly reliant on operator skills, and cannot fully display dilated fistulas. It lacks the capacity to provide a three-dimensional visualization of CAF and lacks intuitiveness. This limitation becomes especially conspicuous when evaluating small, tortuous fistulas, distal fistulae, or multiple fistulas. Specifically, CAFs that drain into the pulmonary artery are prone to being overlooked due to their small fistula size, absence of significant dilation, and minimal shunt flow [19]. In this study, TTE exhibited the highest number of missed diagnoses for coronary artery-pulmonary artery fistulas, with 113 cases missed, constituting 77.9% (113/145) of all missed cases.
CCTA provides high spatial and temporal resolution, as well as powerful post-processing techniques, such as maximum intensity projection (MIP), multiplanar reformation (MPR), curved planar reformation (CPR), and volume rendering (VR). These capabilities allow for a comprehensive evaluation of CAF from different perspectives, including the origin, drainage site, complexity, and characteristics of the fistula, such as its course, morphology, number, and size [20]. However, suboptimal image acquisition resulting from factors, like patient discomfort (for instance, anxiety or arrhythmia), the existence of multiple calcifications, myocardial bridging, or small fistulas obscured by other structures, can lead to misdiagnosis [21]. In this study, the accuracy of CCTA for diagnosing CAF was 78.0% (156/200), with 44 cases missing. The principal reasons for missed diagnoses were the small size, tortuous course, and complexity of the fistulas or the presence of extremely small drainage sites that were difficult to visualize, constituting 63.6% (28/44) of all missed cases. Additionally, poor image quality, such as motion artifacts caused by cardiac pulsation, resulted in blurry visualization of the fistula course and constituted 15.9% (7/44) of all missed cases.
Previous research studies have explored similar topics. Ouchi et al. [15] conducted TTE examinations on 52 patients with CAF. Color Doppler ultrasound detected abnormal blood flow in these patients, with 12 patients suggesting the presence of CAF, resulting in an accuracy of 23.1%. These results align with our findings, indicating that TTE has limited diagnostic value for identifying CAF. Conversely, Xie Mingxing and colleagues [16] conducted a retrospective study on 63 patients who underwent TTE before DSA and/or surgery. They reported a diagnostic concordance with surgery and/or DSA results in 60 patients, achieving an accuracy of 95.2%. This contrasts significantly with our study's conclusions, and the discrepancy may be attributed to differences in sample size, technical proficiency, and operator experience. While studies specifically evaluating the diagnostic value of CCTA for CAF are currently scarce, some studies indicate that CCTA can provide a comprehensive evaluation of complex blood vessels and associated cardiac abnormalities. It is considered a preferred non-invasive imaging method for detecting detailed anatomical information regarding concomitant congenital heart malformations, proving effective, accurate, and diagnostically reliable [22-24].
In clinical practice, accurate diagnosis of CAF is of crucial importance for formulating treatment strategies. The abundant information provided by CCTA helps doctors comprehensively understand the lesion conditions, enabling them to select treatment options more precisely, such as determining whether transcatheter closure or surgical treatment is appropriate and planning the surgical approach. In addition, CCTA also has significant value in postoperative follow-up. It can clearly display the position of the occluder and the situation of residual shunt, and promptly detect and handle possible complications [20, 25].
This study has involved several limitations. First, it was a single-center study. Second, due to the lack of negative cases, the evaluation of the two diagnostic methods was limited. In future research, the experimental design will be refined to conduct a more comprehensive assessment of their diagnostic performance. Third, due to the late development of MRCA, there exists a lack of research on the diagnostic value of MRCA for identifying CAF. Fourth, transesophageal echocardiography can obtain clearer images and help improve the detection rate of CAF. However, it has the risk of invasiveness and thus was not considered in this study.
CONCLUSION
In conclusion, CCTA offers several advantages, such as rapid and clear imaging, non-invasiveness, and convenience of follow-up. It can provide the spatial structure and anatomical details of CAF, along with information on other concurrent heart diseases. Its diagnostic value is significantly higher than that of TTE, making it the preferred examination method for diagnosing CAF. This may potentially lead to corresponding adjustments in the clinical guidelines for the diagnosis and treatment process of CAF, including preoperative diagnosis and evaluation, formulation of surgical plans, and postoperative follow-up assessment.
AUTHORS’ CONTRIBUTIONS
The authors confirm their contribution to the paper as follows: study conception and design: CLH, PH, JX; data collection: YKC, YML; analysis and interpretation of results: SG; drafting of the manuscript: XLH, JS. All authors have reviewed the results and approved the final version of the manuscript.
ACKNOWLEDGEMENTS
We appreciate the contributions of those who participated in data analysis, drafting, and critical revisions.
LIST OF ABBREVIATIONS
- CAF
Coronary artery fistula
- CT
Computed tomography
- CCTA
Cardiac computed tomographic angiography
- CPR
Curved planar reformation
- DSA
Digital subtraction angiography
- HU
Hounsfield unit
- MIP
Maximum intensity projection
- MPR
Multiplanar reformation
- ROI
Region of interest
- TTE
Transthoracic echocardiography
- VR
Volume rendering
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
This study was approved by the ethics committee of the Asia Heart Hospital, China (ethics no. 2022-13031).
HUMAN AND ANIMAL RIGHTS
All the human procedures conducted were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013 (http://ethics.iit.edu/ecodes/node/3931).
CONSENT FOR PUBLICATION
All patients signed an informed consent form.
STANDARDS OF REPORTING
STROBE guidelines were followed.
AVAILABILITY OF DATA AND MATERIALS
The data and supportive information are available within the article.
FUNDING
This work was supported by the Scientific Research Project of Wuhan Municipal Health Commission, China (Grant No. WX23Z75).
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.
REFERENCES
- 1.Cai R., Ma X., Zhao X., Xu J., Zhu L., Ku L. CTA analysis of 482 cases of coronary artery fistula: A large‐scale imaging study. J. Card. Surg. 2022;37(7):2172–2181. doi: 10.1111/jocs.16500. [DOI] [PubMed] [Google Scholar]
- 2.Podolec J., Wiewiórka Ł., Siudak Z., Malinowski K., Bartuś K., Dudek D., Żmudka K., Legutko J. Presence and characteristics of coronary artery fistulas among patients undergoing coronary angiography. Kardiol. Pol. 2019;77(11):1034–1039. doi: 10.33963/KP.14963. [DOI] [PubMed] [Google Scholar]
- 3.Balestrini C.S., Saaibi J.F., Ortiz S.N. Aorto‐right atrial fistula secondary to rupture of an occluded old saphenous venous graft to right coronary artery. Catheter. Cardiovasc. Interv. 2014;84(3):513–518. doi: 10.1002/ccd.24859. [DOI] [PubMed] [Google Scholar]
- 4.Vaidya Y.P., Green G.R. Coronary artery fistula. J. Card. Surg. 2019;34(12):1608–1616. doi: 10.1111/jocs.14267. [DOI] [PubMed] [Google Scholar]
- 5.Acharya D., Litovsky S., Papapietro S.E., Pamboukian S.V., Tallaj J.A. Coronary artery fistula after cardiac transplantation. Circulation. 2012;126(17):2144–2145. doi: 10.1161/CIRCULATIONAHA.112.115519. [DOI] [PubMed] [Google Scholar]
- 6.Bagai A., Lu J., Al-Amro B., Rezende-Neto J., Prabhudesai V., Ackery A.D., Yanagawa B. Management of right coronary artery fistula caused by nail gun trauma. J. Thorac. Cardiovasc. Surg. 2016;152(6):e139–e141. doi: 10.1016/j.jtcvs.2016.07.086. [DOI] [PubMed] [Google Scholar]
- 7.Anastacio M.M., Lee A.M., Lawton J.S. Congenital fistula from the left main coronary artery to the left atrium presenting with an acute myocardial infarction. J. Thorac. Cardiovasc. Surg. 2012;144(6):e147–e148. doi: 10.1016/j.jtcvs.2012.09.015. [DOI] [PubMed] [Google Scholar]
- 8.Qin Z., Gong B., Luo L., Ge L. One-stop procedure of “atrial fibrillation radiofrequency ablation + left atrial appendage closure + coronary artery fistula embolization”: A case report. Perfusion. 2023;38(7):1526–1529. doi: 10.1177/02676591221113646. [DOI] [PubMed] [Google Scholar]
- 9.McLarry J., Ferencik M., Shapiro M.D. Coronary Artery Anomalies: A Pictorial Review. Curr. Cardiovasc. Imaging Rep. 2015;8(7):23. doi: 10.1007/s12410-015-9339-8. [DOI] [Google Scholar]
- 10.Lim JJ, Jung JI, Lee BY, et al. Prevalence and types of coronary artery fistulas detected with coronary CT angiography. AJR Am J Roentgenol. 2014;203(3):W237–W243. doi: 10.2214/AJR.13.11613. [DOI] [PubMed] [Google Scholar]
- 11.Zhang Y., Zhang X., Jiang Y., Yang P., Hu X., Peng B., Yue X., Li Y., Ma P., Yuan Y., Yu Y., Liu B., Li X. 3D whole-heart noncontrast coronary MR angiography based on compressed SENSE technology: A comparative study of conventional SENSE sequence and coronary computed tomography angiography. Insights Imaging. 2023;14(1):35. doi: 10.1186/s13244-023-01378-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Chen Y., Guo H., Dong P., Li Y., Zhang Z., Mao N., Chu T., Sun Z., Wang F., Feng Z., Wang H., Ma H. Feasibility of 3.0 T balanced fast field echo non-contrast-enhanced whole-heart coronary magnetic resonance angiography. Cardiovasc. Diagn. Ther. 2023;13(1):51–60. doi: 10.21037/cdt-22-487. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Scott A.D., Keegan J., Firmin D.N. Motion in cardiovascular MR imaging. Radiology. 2009;250(2):331–351. doi: 10.1148/radiol.2502071998. [DOI] [PubMed] [Google Scholar]
- 14.Lee S.E., Sung J.M., Rizvi A., Lin F.Y., Kumar A., Hadamitzky M., Kim Y.J., Conte E., Andreini D., Pontone G., Budoff M.J., Gottlieb I., Lee B.K., Chun E.J., Cademartiri F., Maffei E., Marques H., Leipsic J.A., Shin S., Hyun Choi J., Chinnaiyan K., Raff G., Virmani R., Samady H., Stone P.H., Berman D.S., Narula J., Shaw L.J., Bax J.J., Min J.K., Chang H.J. Quantification of Coronary Atherosclerosis in the Assessment of Coronary Artery Disease. Circ. Cardiovasc. Imaging. 2018;11(7):e007562. doi: 10.1161/CIRCIMAGING.117.007562. [DOI] [PubMed] [Google Scholar]
- 15.Ouchi K., Sakuma T., Ojiri H. Coronary artery fistula in adults: Incidence and appearance on cardiac computed tomography and comparison of detectability and hemodynamic effects with those on transthoracic echocardiography. J. Cardiol. 2020;76(6):593–600. doi: 10.1016/j.jjcc.2020.06.005. [DOI] [PubMed] [Google Scholar]
- 16.Xie M., Li L., Cheng T.O., Sun Z., Wang X., Lv Q., Peng H., Yuan L., Wang J., Zhang L. Coronary artery fistula: Comparison of diagnostic accuracy by echocardiography versus coronary arteriography and surgery in 63 patients studied between 2002 and 2012 in a single medical center in China. Int. J. Cardiol. 2014;176(2):470–477. doi: 10.1016/j.ijcard.2014.07.198. [DOI] [PubMed] [Google Scholar]
- 17.Shrestha Arati S., Jin J.Y. Coronary Artery Fistula and Its Imaging Modalities—A Review Article. Open J. Radiol. 2017;7(2):121–129. doi: 10.4236/ojrad.2017.72014. [DOI] [Google Scholar]
- 18.Gowda R.M., Vasavada B.C., Khan I.A. Coronary artery fistulas: Clinical and therapeutic considerations. Int. J. Cardiol. 2006;107(1):7–10. doi: 10.1016/j.ijcard.2005.01.067. [DOI] [PubMed] [Google Scholar]
- 19.Atik S.U., Saltik I.L. Incidentally detected small fistula flows in pulmonary artery by colour Doppler: Echocardiographic findings and follow-up results. Cardiol. Young. 2019;29(12):1435–1439. doi: 10.1017/S1047951119002051. [DOI] [PubMed] [Google Scholar]
- 20.Sharma A., Pandey N.N., Kumar S. Imaging of coronary artery fistulas by multidetector CT angiography using third generation dual source CT scanner. Clin. Imaging. 2019;53:89–96. doi: 10.1016/j.clinimag.2018.09.019. [DOI] [PubMed] [Google Scholar]
- 21.Byun S.S., Park J.H., Kim J.H., Sung Y.M., Kim Y.K., Kim E.Y., Park E.A. Coronary CT findings of coronary to bronchial arterial communication in chronic pulmonary disease. Int. J. Cardiovasc. Imaging. 2015;31(S1) Suppl. 1:69–75. doi: 10.1007/s10554-015-0647-5. [DOI] [PubMed] [Google Scholar]
- 22.D’Angelo T., Lenga L., Arendt C.T., Bucher A.M., Peterke J.L., Caruso D., Mazziotti S., Ascenti G., Blandino A., Othman A.E., Martin S.S., Albrecht M.H., Bodelle B., Vogl T.J., Wichmann J.L. Carotid and cerebrovascular dual-energy computed tomography angiography: Optimization of window settings for virtual monoenergetic imaging reconstruction. Eur. J. Radiol. 2020;130:109166. doi: 10.1016/j.ejrad.2020.109166. [DOI] [PubMed] [Google Scholar]
- 23.Czekajska-Chehab E., Skoczyński M., Przybylski P., Staśkiewicz G., Tomaszewski A., Siek E., Kurzepa J., Skoczyński M., Drop A. Coronary artery fistulas morphology in coronary computed tomography angiography. Folia Morphol. (Warsz) 2020;79(4):777–785. doi: 10.5603/FM.a2019.0132. [DOI] [PubMed] [Google Scholar]
- 24.D’Angelo T., Cicero G., Mazziotti S., Ascenti G., Albrecht M.H., Martin S.S., Othman A.E., Vogl T.J., Wichmann J.L. Dual energy computed tomography virtual monoenergetic imaging: Technique and clinical applications. Br. J. Radiol. 2019;92(1098):20180546. doi: 10.1259/bjr.20180546. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Jama A., Barsoum M., Bjarnason H., Holmes D.R., Jr, Rihal C.S. Percutaneous closure of congenital coronary artery fistulae: Results and angiographic follow-up. JACC Cardiovasc. Interv. 2011;4(7):814–821. doi: 10.1016/j.jcin.2011.03.014. [DOI] [PubMed] [Google Scholar]
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Data Availability Statement
The data and supportive information are available within the article.