Endovascular management of a coronary artery to pulmonary artery fistula with detachable balloons: a case report

A 28-year-old woman was referred for cardiac evaluation of a continuous murmur. The murmur was detected on physical examination by a gynaecologist during work up for possible hysterectomy for severe menorrhagia. The patient had no chest pain or palpitations but reported dyspnoea on exertion. There was no history of congenital cardiac anomalies or surgical interventions on the chest. On examination, the peripheral pulses were normal and there was no pedal oedema. A continuous murmur was again noted on auscultation of the heart. An electrocardiogram was normal with no signs of myocardial ischemia or arrhythmia. An echocardiography demonstrated a large coronary artery to pulmonary artery fistula between the left anterior descending (LAD) coronary artery and the main pulmonary artery. The heart chambers were normal with normal valvular function. There was no pericardial effusion. The left ventricular ejection fraction was normal. Subsequently, a coronary angiography was performed through a trans-femoral route. This confirmed the presence of a large fistula between the LAD coronary artery and the main pulmonary artery. The fistulous connection was seen as a tortuous vessel coursing in a curvilinear fashion towards the main pulmonary artery (Figure 1). In addition, another small fistula was seen between the proximal LAD coronary artery to the main pulmonary artery. There was relative hypo-perfusion of the branches of the LAD coronary artery and the left circumflex coronary artery. Given the presence of exertional dyspnoea and coronary hypoperfusion secondary to the fistula, endovascular occlusion of the fistula was considered. Detachable balloons were considered for occlusion of the large fistula due to the size of the fistula and the tortuous course of the artery. Endovascular coil embolization was considered for the small fistula given its size and straighter course