J Korean Soc Radiol.  2014 Jun;70(6):415-418. 10.3348/jksr.2014.70.6.415.

Coronary-to-Bronchial Artery Fistula Originating from the S-Shaped Sinoatrial Node Artery: CT and Angiography Findings

• Beck KS
• Lee BY
• Cho EJ

• KMID: 1941768
• DOI: http://doi.org/10.3348/jksr.2014.70.6.415

Abstract

Coronary artery fistula (CAF) is a rare type of anomaly in which a fistulous connection between a coronary artery and another vascular structure is present. Even among CAFs, a connection between a coronary artery and a bronchial artery is not common, and although coronary-bronchial fistula from the sinoatrial node (SAN) artery has been occasionally mentioned in the literature, to our knowledge, a communication between the S-shaped variant of SAN artery and the bronchial artery has not been reported before. We recently experienced a unique case of coronary-to-bronchial artery fistula originating from the S-shaped SAN artery in an 85-year-old male with nocturnal chest pain and would like to discuss its CT and coronary angiography findings.

MeSH Terms

Aged, 80 and over
Angiography*
Arteries*
Arterio-Arterial Fistula
Bronchial Arteries
Chest Pain
Coronary Angiography
Coronary Vessel Anomalies
Coronary Vessels
Fistula*
Humans
Male
Multidetector Computed Tomography
Sinoatrial Node*

Figure

• 

  Fig. 1 A 85-year-old man with an incidentally detected coronary-to-bronchial artery fistula. A. Selective coronary angiography through the left main coronary artery shows a tortuous vessel (arrow) arising from the proximal portion of the left circumflex artery, coursing upwards and branching into two smaller vessels: the larger branch (arrowheads) coursing towards both lungs and dividing into smaller branches that are bronchial arteries and another tiny branch (arrow), which later proved to be the distal portion of the S-shaped sinoatrial node (SAN) artery. B, C. Contrast-enhanced axial CT images of the heart reveal the S-shaped SAN artery (arrows) arising from the posterolateral part of the left circumflex artery behind the left atrial appendage. It then runs posteriorly between the ostium of the left pulmonary vein and anteriorly close to the anterior wall of the left atrium (LA). D, E. Maximum intensity projection image (D) and transparent volume-rendered image (E) of the heart depict the course of the S-shaped SAN artery and the coronary artery fistula arising from it. A tortuous vessel (arrows) arising from the posterolateral part of the left circumflex atery behind the left atrial appendage runs along the superior aspect of the LA and terminates near the superior vena cava. The course of this tortuous vessel (arrows) is the same as that of the S-shaped SAN artery, thus identifying the vessel to be the S-shaped SAN artery. At the posterosuperior aspect of the LA, another tortuous vessel (arrowheads) arises from the S-shaped SAN artery, coursing upwards towards the lungs, confirming the presence of SAN artery-to-bronchial artery fistula. F. Another volume-rendered image well demonstrates the relationship of the S-shaped SAN artery (arrows) running between the left atrial appendage and the pulmonary vein (the pulmonary vein and the left atrial appendage are partially removed to reveal the artery). The bronchial artery (arrowheads) arises from the middle of the S-shaped SAN artery (arrows). G. Maximum intensity projection image of the lungs reveals the bronchial arteries (arrowheads) arising from the S-shaped SAN artery (arrows) and running toward both lungs. There is no definite abnormality in the lung parenchyma. Note.-Ao = aorta, LA = left atrium, LAA = left atrial appendage, LCX = left circumflex artery, LIPV = left inferior pulmonary vein, LSPV = left superior pulmonary vein, RA = right atrium, RV = right ventricle, SVC = superior vena cava

Reference

1. Vavuranakis M, Bush CA, Boudoulas H. Coronary artery fistulas in adults: incidence, angiographic characteristics, natural history. Cathet Cardiovasc Diagn. 1995; 35:116–120.

2. Zhou CS, Zhang LJ, Wang YN, Yu W, Huang W, Zhang B, et al. [Incidence and classification diagnosis of coronary artery fistula at dual-source CT coronary angiography]. Zhonghua Yi Xue Za Zhi. 2012; 92:3336–3340.

3. Zenooz NA, Habibi R, Mammen L, Finn JP, Gilkeson RC. Coronary artery fistulas: CT findings. Radiographics. 2009; 29:781–789.

4. Matsunaga N, Hayashi K, Sakamoto I, Ogawa Y, Matsuoka Y, Imamura T, et al. Coronary-to-pulmonary artery shunts via the bronchial artery: analysis of cineangiographic studies. Radiology. 1993; 186:877–882.

5. Lee ST, Kim SY, Hur G, Hwang YJ, Kim YH, Seo JW, et al. Coronary-to-bronchial artery fistula: demonstration by 64-multidetector computed tomography with retrospective electrocardiogram-gated reconstructions. J Comput Assist Tomogr. 2008; 32:444–447.

6. Saremi F, Channual S, Abolhoda A, Gurudevan SV, Narula J, Milliken JC. MDCT of the S-shaped sinoatrial node artery. AJR Am J Roentgenol. 2008; 190:1569–1575.

7. Yoon JY, Jeon EY, Lee IJ, Koh SH. Coronary to bronchial artery fistula causing massive hemoptysis in patients with longstanding pulmonary tuberculosis. Korean J Radiol. 2012; 13:102–106.

8. Cho J, Shin T, Jun K, Ryoo J, Choi H, Choi B, et al. Transcatheter embolization of bronchial artery arising from left circumflex coronary artery in a patient with massive hemoptysis. Cardiovasc Intervent Radiol. 2010; 33:169–172.