Bilateral communicating coronary arteriovenous fistulas presenting with recurrent angina

Chiu-Fen Yang^{a, d}, Shu-Hsin Liu^{b, d}, Jing-Ren Jeng^{c, d}, Michael Yu-Chih Chen^{c, d}

^a Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
^b Department of Nuclear Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
^c Department of Cardiology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
^d Department of Cardiology, Tzu Chi University, Hualien, Taiwan

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Abstract
Coronary fistula is a rare disorder. Early diagnosis is difficult because angina caused by stenosis secondary to coronary atheroma is very similar to the coronary steal phenomenon. We report the case of a 51-year-old man who presented with recurrent angina over an 8-year period in whom bilateral coronary fistulas were detected by conventional coronary angiography. Sixty-four-slice multidetector computed tomography (MDCT) showed bilateral coronary fistulas merging to form an aneurysm before entering the pulmonary artery. However, thallium201 single-photon emission computed tomographic (SPECT) myocardial perfusion imaging showed only inferior apical ischemia. The combined use of these techniques showed the detailed anatomy of the fistula and the degree of myocardial ischemia for clinical planning. Both MDCT and SPECT are important diagnostic tools and should be considered in the clinical evaluation of bilateral coronary fistulas.

Keywords
Angina; Bilateral; Congenital; Coronary abnormality; Coronary artery fistula