Coronary Malformation With Multiple Fistulae

A 55-year-old man with cardiovascular risk factors such as hypertension, hyperlipidaemia, positive family history and nicotin abuse, was referred for coronary angiography (CAG) for evaluation of a 1.5 year history of atypical chest pain and dyspnoea which had progressively worsened prior to admission. CAG demonstrated diffuse hemodynamically not relevant arteriosclerotic lesions without any critical stenosis, and a normal global systolic function of the left ventricle (ejection fraction=67%). Furthermore, selective angiography of the left descending coronary artery (LAD) revealed a conglomerate of slowly filling, anomalous vessels with multiple fistulas (see Fig. 1A), of which two communications to the descending aorta were the most obvious one at CAG. Subsequently, ECG-triggered multidetector computed tomography (CT) was indicated for further topographic overview. CT coronary angiography (CTA)was performed on a 64-slice scanner (VCT,General Electrics,Milwaukee,Minnesota) utilizing retrospectively gated data acquisition during intravenous administration of 60 ml of iodinated contrast agent (Iopromide, Ultravist 370; Bayer HealthCare Pharmaceuticals Inc., Wayne, NJ), at a rate of 5 ml s−1. The following scan parameters were implemented: collimation, 64×0.6 mm; helical pitch, 0.33; rotation time, 330 ms, tube voltage, 120 kV; and ECGadapted tube current, with a maximum at 800 mA. Scanning was performed in craniocaudal direction from the aortic arch to the level of