Local pulmonary malformation caused by bilateral coronary artery and bronchial artery fistulae to the left pulmonary artery in a patient with coronary artery disease

Abstract

At 10 years of age and again at 25, our patient had been treated for pulmonary tuberculosis due to the presence of a localized pulmonary shadow. Coronary angiography at age 59 revealed 3 fistulous communications: from the right and circumflex coronary arteries and from the left bronchial artery. All 3 emptied into the same recipient artery, the distal part of a left pulmonary artery branch, which produced substantial left-to-right shunt. On computed tomography, cystic formations could be seen in the pulmonic area. The pulmonary tuberculosis for which this patient had been treated in his youth was in the same part of the lung where the shunt was discovered. Our conclusion is that the initial diagnosis was in error.

Fig. 1 Computed tomogram of the chest at the level between the pulmonary artery and the left atrium. The cystic formation in the left basal part of the left lung is seen (arrow). Ao = aorta; LV = left ventricle; PA = pulmonary artery

Fig. 2 Right coronary artery (RCA) arteriogram in right oblique projection. An aberrant tortuous artery arises from the proximal segment of the RCA (A) and drains to the network and cavity positioned in the left basal part of the left lung (B). The fistula, which arises just before the proximal stenosis of the RCA (arrow), is of the same caliber as the coronary artery and passes near the left atrium, to the distal branch of the pulmonary artery. F = fistula; K = catheter; NET = network; RCA = right coronary artery

Fig. 3 The left coronary artery in right anterior projection. A large vessel (arrow) originates from the distal circumflex coronary artery (LCX) and drains into the pulmonary artery (PA).

Fig. 4 Selective pulmonary angiography of the right coronary artery in the left anterior oblique projection. The distal part of the fistulous connection (F) with the pulmonary artery is seen (arrow). F = fistula; LA = left atrium; PA = left branch of the pulmonary artery

Fig. 5 Angiogram of the right coronary artery in the lateral projection. The distal part of the fistulous connection (F) with the pulmonary artery is seen. The network (NET) surrounds the cystic formation in the lung and contrast medium is seen emptying into the pulmonary artery branch (arrow). Observe the left-to-right shunt.

Fig. 6 Angiogram of the bronchial artery (BA) in the right anterior projection. The tortuous vessel drains into the lung network.