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Case series of a rare complication of CABG

Fistula between the internal mammary artery and pulmonary vasculature

Fallserie zu einer seltenen Komplikation beim Koronarbypass

Fistelbildung zwischen A. mammaria interna und Lungengefäßen

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Abstract

Background

There are few reports in the literature on the development of a fistulous connection between the left internal mammary artery (LIMA) and the pulmonary vasculature (PV) after coronary artery bypass grafting (CABG). This type of fistula may cause angina after CABG. Various mechanisms in the pathophysiology of this rare condition have been proposed.

Methods

We evaluated 537 consecutive patients with CABG surgery who underwent coronary angiography at our institution between January 2011 and March 2012. The post-CABG angiograms were evaluated for LIMA–PV fistula formation. Presence of a LIMA–PV fistula was defined as opacification of the PV or parenchyma after injection of radiopaque contrast medium into the LIMA.

Results

We found that 5 of 537 patients (0.93 %) had a LIMA–PV fistula on post-CABG coronary angiograms. The mean age of patients with a LIMA–PV fistula was 61.4 years (range, 51–72 years) and all patients were male. Coronary angiography was performed in the setting of myocardial infarction for 2 patients with a LIMA–PV fistula, and stable angina pectoris was the indication for coronary angiography in the remaining 3 patients. The mean diagnosis time of LIMA–PV fistula after CABG was 3.4 years (range, 1–9 years). None of the patients had a history of redo-CABG, perioperative mediastinitis, or pneumonia.

Conclusion

LIMA–PV fistulas may occur more frequently than reported on post-CABG angiogram findings. Angina in post-CABG patients may be associated with a LIMA–PV fistula, and selective cannulation of the LIMA with careful evaluation of the angiographic images may provide proper diagnosis and treatment of this entity.

Zusammenfassung

Hintergrund

Die Entwicklung einer Fistelverbindung zwischen der linken A. mammaria interna (LIMA) und Lungengefäßen (PV) nach Koronararterienbypass-Op. („coronary artery bypass graft“, CABG) wird nur selten in der Literatur beschrieben. Symptom kann eine Angina in der Zeit nach der CABG sein; es wurden verschiedene Mechanismen zur Pathophysiologie dieser seltenen Erkrankung erwogen.

Methoden

Ausgewertet wurden die Daten von 537 konsekutiven Patienten mit CABG, bei denen in unserem Institut zwischen Januar 2011 und März 2012 eine Koronarangiographie durchgeführt wurde. Die Angiographien nach CABG wurden im Hinblick auf eine Fistelbildung zwischen LIMA und PV geprüft. Das Vorliegen einer LIMA-PV-Fistel wurde nach Injektion eines radioopaken Kontrastmittels in die LIMA als Verschattung der Lungengefäße oder des Lungenparenchyms in den folgenden Sequenzen definiert.

Ergebnisse

Eine Fistel zwischen LIMA und PV fand sich bei 5 von 537 Patienten (0,93%) in der Koronarangiographie nach CABG. Das Durchschnittsalter der Patienten mit LIMA-PV-Fistel betrug 61,4 Jahre (Spannweite: 51–72 Jahre), alle Patienten waren männlich. Bei 2 dieser Patienten mit LIMA-PV-Fistel wurde die Koronarangiographie wegen eines Myokardinfarkts und bei den restlichen 3 Patienten wegen stabiler Angina pectoris durchgeführt. Die mittlere Zeit bis zur Diagnose der LIMA-PV-Fistel nach CABG lag bei 3,4 Jahren (Spannweite: 1–9 Jahre). Bei keinem der Patienten gab es eine Re-CABG, perioperative Mediastinitis oder Pneumonie in der Anamnese.

Schlussfolgerung

LIMA-PV-Fisteln sind möglicherweise öfter als beschrieben in Angiographien nach CABG zu finden. Eine Angina bei Patienten nach erfolgter CABG kann im Zusammenhang mit einer LIMA-PV-Fistel stehen; die selektive Kanülierung der LIMA und sorgfältige Befundung der Angiographiebilder ermöglichen die richtige Diagnose und Behandlung dieser Erkrankung.

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Conflict of interest

On behalf of all authors, the corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Cardiology Clinic, Koşuyolu Heart & Research Hospital, 34846, Kartal, Istanbul, Turkey

    A. Guler, M. Yildiz, C.Y. Karabay, S.M. Aung, A.C. Aykan, A. Karagoz, Y. Guler, A.M. Esen & C. Kirma

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  1. A. Guler
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  2. M. Yildiz
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  3. C.Y. Karabay
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  4. S.M. Aung
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  5. A.C. Aykan
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  6. A. Karagoz
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  7. Y. Guler
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  8. A.M. Esen
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Correspondence to A. Guler.

Electronic supplementary material

59_2013_3814_MO1_ESM.mov

vVideo 1. Patient 1: Selective IMA angiography demonstrating a fistula from IMA and it’s side branch to the left pulmonary artery (QuickTime MOV MB)

59_2013_3814_MO2_ESM.mov

Video 2. Patient 2: IMA angiography showed fistulous communications between IMA and left upper lobe pulmonary vein (QuickTime MOV MB)

59_2013_3814_MO3_ESM.mov

Video 3. Patient 3: On selective IMA angiography, IMA wasn’t perfusing to LAD and small fistulous connections between was seen (QuickTime MOV MB)

59_2013_3814_MO4_ESM.mov

Video 4. Patient 4: Selective angiography of IMA showing coil embolization device in the intercostal branch and multiple spiral fistulous connections between IMA and pulmonary artery (QuickTime MOV MB)

59_2013_3814_MO5_ESM.mov

Video 5. Patient 5: Selective IMA injection demonstrating a gross opacification of pulmonary artery from IMA (QuickTime MOV MB)

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Guler, A., Yildiz, M., Karabay, C. et al. Case series of a rare complication of CABG. Herz 39, 149–153 (2014). https://doi.org/10.1007/s00059-013-3814-2

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  • DOI: https://doi.org/10.1007/s00059-013-3814-2

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