Journal Information
Vol. 37. Issue 4.
Pages 355-357 (April 2018)
Download PDF
More article options
Vol. 37. Issue 4.
Pages 355-357 (April 2018)
Image in Cardiology
DOI: 10.1016/j.repce.2017.03.011
Open Access
Acquired fistula from left anterior descending artery to coronary sinus: An unusual finding during percutaneous coronary intervention
Fístula coronária adquirida da artéria descendente anterior para o seio coronário: um achado raro durante uma intervenção coronária percutânea
Ana Rita G. Franciscoa,
Corresponding author

Corresponding author.
, Miguel Nobre de Menezesa, Fausto J. Pintob, Pedro Canas da Silvaa
a Cardiology Department, Santa Maria University Hospital, CHLN, CAML, CCUL, University of Lisbon, Lisbon, Portugal
b Cardiology Department, Santa Maria University Hospital, CHLN, CA, Lisbon, Portugal
Article information
Full Text
Download PDF
Figures (3)
Show moreShow less
Additional material (1)
Full Text

A 64-year-old Caucasian male with a history of coronary artery bypass grafting (CABG) [internal mammary artery (IMA) graft to the left anterior descending artery (LAD) and saphenous vein graft to right posterior descending artery (PDA)], presented with stable angina with a positive treadmill exercise test. Coronary angiography (CAG) documented occlusion of both middle LAD and IMA grafts (Figure 1, panel A); no significant lesions were found in the circumflex artery or the saphenous vein graft. The CAG performed prior to surgery is shown in Figure 2.

Figure 1.

Panel A: coronary angiography (right cranial view) showing LAD occlusion; Panel B: large caliper vessel uncovered after LAD balloon pre-dilatation (left cranial view); Panel C: documentation of a fistula from the middle segment of the LAD into the coronary sinus by CT angiography.

Figure 2.

Coronary angiography (Panel A: right cranial view; Panel B: right caudal view) showing LAD occlusion prior to the CABG.


After a myocardial perfusion scintigraphy confirming viability in LAD territory, an angioplasty was performed. A new large vessel was visible after mid-LAD dilatation (Figure 1, panel B, supplementary film 1). The images were suggestive of a fistula or a shunt. A 4.0×18-mm drug-eluting stent was successfully implanted. The patient remained stable throughout the procedure.

CT angiography showed a fistula from the middle segment of the LAD to the coronary sinus (Figure 1, panel C). Excluding the fistula by implanting a covered stent was then considered. However, when performing the initial CAG, complete stent restenosis had occurred, resulting in both LAD and fistula occlusion (Figure 3). A silent infarction had probably occurred. A new ischemia test was performed, documenting necrosis without viability. A conservative approach was therefore chosen.

Figure 3.

Coronary angiography (Panel A: right caudal view; Panel B: right cranial view) showing LAD occlusion prior to the stent. Panel C: right-sided collaterals filling the distal LAD seen after saphenous vein graft catheterization.


Coronary artery fistulas (CAFs) are uncommon. Acquired fistulas are even rarer, and may occur after cardiac trauma, angioplasty, endomyocardial biopsies or cardiac surgery. We describe the rare case of fistula development after CABG. Although the majority of patients are asymptomatic, they can present with angina pectoris or myocardial infarction. In this particular case, due to steal phenomenon, this acquired CAF may have led to both IMA graft and LAD occlusion. Treatment should be considered for symptomatic patients or documented ischemia. Options range from a conservative approach to coil embolization, PTFE stent deployment or surgery.

Conflict of interests

The authors have no conflicts of interest to declare.

Copyright © 2018. Sociedade Portuguesa de Cardiologia
Revista Portuguesa de Cardiologia (English edition)

Subscribe to our newsletter

Article options
Supplemental materials
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

By checking that you are a health professional, you are stating that you are aware and accept that the Portuguese Journal of Cardiology (RPC) is the Data Controller that processes the personal information of users of its website, with its registered office at Campo Grande, n.º 28, 13.º, 1700-093 Lisbon, telephone 217 970 685 and 217 817 630, fax 217 931 095, and email I declare for all purposes that the information provided herein is accurate and correct.