A 32-year-old man, a chronic smoker, presented with a 2-month history of persistent coughing without purulent sputum or hemoptysis. His blood pressure, respiratory rate, and breath sounds were normal; however, a continuous murmur was heard in the aortic area. Laboratory tests and electrocardiography revealed no abnormalities. A chest radiograph showed a mild expansion on the right-heart border. Thoracic computed tomography revealed tortuous cardiac vascular structures. Computed tomographic angiograms showed a tortuous, dilated right coronary artery (RCA) and coronary sinus (CS) (Figs. 1, 2, and 3). At the point of maximal dilation, the RCA was 19.9 mm and the CS was 32 mm. They joined at a point 10 mm proximal to the CS–right atrial junction. The posterior descending artery was normal. The patient declined conventional angiography and was discharged with medical counseling.
Fig. 1 Computed tomographic angiogram (volume-rendered posterior image) shows an enlarged coronary sinus (CS), an enlarged right coronary artery (RCA), and a normal posterior descending artery.
Fig. 2 Computed tomographic angiogram (volume-rendered superior image) shows a dilated, tortuous right coronary artery (RCA).
CS = coronary sinus
Fig. 3 Curved planar reformation computed tomographic angiogram shows the fistula.
CS = coronary sinus; RCA = right coronary artery
Comment
Coronary artery fistulae were first described in 1865.1 Angiographic series have revealed an incidence of 0.3% to 0.8%.2,3 Approximately 55% of fistulae originate from the RCA, 40% from the left main coronary artery, and 5% from both. These fistulae most often drain into the right ventricle (41%), or into the right atrium (26%), pulmonary artery (17%), CS (7%), left atrium (5%), left ventricle (3%), or superior vena cava (1%). Congenital RCA–CS fistulae are uncommon. Aneurysmatic dilation of the RCA up to 5 cm has been reported,4 but that formation was symptomatic. Our case appears to be one of the largest asymptomatic aneurysmatic coronary artery dilations ever reported.
Footnotes
Address for reprints: Guven Tekbas, MD, Tip Fakultesi Radyoloji, Dicle Universitesi, 21280 Diyarbakir, Turkey
E-mail: drgtekbas@yahoo.com
References
- 1.Krause W. Uber den ursprung einer akzessorischen a. coronaria aus a. pulmonalis [in German]. Z Ratl Med 1865;24:225–7.
- 2.Gowda RM, Vasavada BC, Khan IA. Coronary artery fistulas: clinical and therapeutic considerations. Int J Cardiol 2006;107(1):7–10. [DOI] [PubMed]
- 3.Mitsutake R, Miura S, Shiga Y, Iwata A, Saku K. Coronary-pulmonary artery fistula with anomalous vessels arising from the right coronary sinus detected by 64-MDCT. Intern Med 2009;48(21):1893–6. [DOI] [PubMed]
- 4.Umezu K, Hanayama N, Toyama A, Hobo K, Takazawa A. Successful repair for a giant coronary artery aneurysm with coronary arteriovenous fistula complicated by both right- and left-sided infective endocarditis. Gen Thorac Cardiovasc Surg 2009;57(10):544–6. [DOI] [PubMed]