Coronary artery fistulas and persistent Thebesian veins presenting as STEMI
Authors: Michael Crawford, MD; Laura Padilla-Carrasquillo, MD; Tariq Thannoun, MD; Rohan Samson, MD
Introduction : A coronary artery fistula (CAF) is an anomalous communication between a coronary artery and a cardiac chamber without an intervening capillary network. While generally asymptomatic, they may result in ischemia, heart failure, or arrhythmia. In contrast to CAFs, which have a noticeable communication, smaller fistulas or persistent Thebesian veins, are rarer entities that form an intramural vascular network prior to emptying into the ventricle. Here, we present a unique case of a patient with CAFs draining into the right ventricle (RV) and persistent Thebesian veins draining into the left ventricle (LV). Case presentation : A 66-year-old man presented with chest pain relieved with nitroglycerin. Initial electrocardiogram (ECG) showed ST elevations in the anteroseptal leads. Troponin I level was normal. Coronary angiography revealed no epicardial coronary artery disease. However, injection of the left anterior descending and right coronary arteries revealed large caliber vessels with distal communications into the RV apex creating a ventriculogram. Of greater interest, injection of the left circumflex artery resulted in a marked capillary blush within the LV wall due to an extensive vascular network that ultimately drained into the LV creating a ventriculogram. Echocardiography showed evidence of anomalous flow into the RV and LV via color doppler. Coronary computed tomography angiography confirmed the findings previously described. Symptoms and ECG changes resolved. He was treated with aggressive risk factor modification. Discussion : CAFs and persistent Thebesian veins have been noted in <0.3% of adults undergoing coronary angiography. While typically isolated, they may be associated with other cardiac malformations such as atrial or ventricular septal defects. Most CAFs are congenital in nature but can be acquired from iatrogenic events such as stenting or bypass surgery. Symptoms are rare but may occur from a coronary “steal” phenomenon causing myocardial ischemia. First-line treatment is medical therapy, but closure of CAFs with coil occlusion or surgical ligation may be considered in the setting of significant shunting or persistent ischemia.
Conclusion :
CAFs and persistent Thebesian veins are rare anatomic abnormalities of the coronary arteries. While often silent, they can lead to symptoms or complications that may prompt intervention.
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