Korean J Radiol.  2019 Nov;20(11):1491-1497. 10.3348/kjr.2019.0331.

Coronary-to-Pulmonary Artery Fistula in Adults: Natural History and Management Strategies

• Kim H
• Beck KS
• Choe YH
• Jung JI

• KMID: 2459417
• DOI: http://doi.org/10.3348/kjr.2019.0331

Abstract

OBJECTIVE
To evaluate the natural course of coronary-to-pulmonary artery fistula (CPAF) detected on coronary computed tomography angiography (CCTA) and to propose potential treatment strategies.
MATERIALS AND METHODS
In this retrospective multicenter study, we assessed the CCTA reports of 188 CPAF patients evaluated between March 2009 and June 2016. Fifty-seven patients were excluded because their follow-up (FU) periods were less than 2 years. Information regarding demographic characteristics, past history, treatment method, and the occurrence of major adverse cardiac events (MACE) during the FU period was collected. We analyzed the morphologic features of CPAF and the various factors associated with surgical treatment. Patients who had undergone FU CCTA after being diagnosed with CPAF were assessed for the presence of morphological changes on FU imaging.
RESULTS
The median age of the study population was 63.0 years (range, 57.0-72.0 years), and the median FU period was 5.72 years (range, 4.08-6.96 years). The most common origin of the CPAF was both coronary arteries in 76 (58.0%) cases. An aneurysm or aneurysms was/were present in 41 (31.3%) cases. Fifty-four (41.2%) fistulas were less than 2 mm in size. Eight patients underwent surgery, and 123 (93.9%) patients received optimal medical treatment (OMT). The fistula size was significantly different between the two treatment groups (p = 0.013) and was the only factor associated with surgical treatment (odds ratio = 1.14, p = 0.021). Only one patient in the OMT group reported MACE during the FU period due to preexisting coronary artery disease. Twenty-nine patients (22.1%) underwent FU CCTA after CPAF diagnosis, with a median FU period of 3.81 years. None of the patients in the OMT group demonstrated morphological changes in the CPAF on FU imaging.
CONCLUSION
Most CPAFs identified on CCTA have a favorable prognosis. Observation with OMT is usually an appropriate strategy. Fistula size is a possible determinant for surgical treatment.

Keyword

CT angiography; Coronary artery; Pulmonary artery; Vascular fistula; Prognosis; Coronary artery anomaly

MeSH Terms

Adult*
Aneurysm
Angiography
Arteries*
Coronary Artery Disease
Coronary Vessels
Diagnosis
Fistula*
Follow-Up Studies
Humans
Methods
Natural History*
Prognosis
Pulmonary Artery
Retrospective Studies
Vascular Fistula

Figure

• 

  Fig. 1 Flowchart showing inclusion and exclusion of patients in study.CCTA = coronary computed tomography angiography, CPAF = coronary-to-pulmonary artery fistula, OMT = optimal medical treatment

• 

  Fig. 2 CCTA images of 62-year-old man with CPAF.Axial CCTA images show fistula draining from left coronary artery to main pulmonary artery (arrow, A) with several small aneurysmal dilatations (arrowhead, B). Other fistula tract originating from right coronary artery is also seen (arrow, B). C. Three-dimensional volume-rendered image clearly shows CPAF supplied by right coronary artery and left coronary artery (arrowheads) with aneurysmal dilatation (arrow).

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