Multidisciplinary Approach to Closure of a Late-Presenting Large Coronary Artery Fistula

Coronary artery fistulas (CAFs) are rare congenital arteriovenous malformations that are usually incidentally discovered. Once a CAF is confirmed, the management involves surveillance or a transcatheter or surgical intervention for certain patient populations as highlighted herein.

A 63-year-old male bodybuilder presented with lightheadedness and wide complex tachyarrhythmia requiring 2 defibrillator shocks. Coronary angiography revealed a large tortuous coronary fistula from the left main coronary artery/left circumflex artery emptying into the superior vena cava. Due to concerns for coronary steal, a decision was made to intervene. A nonsurgical multidisciplinary approach, utilizing coil embolization, was planned for fistula closure to preserve the patient's active lifestyle. In addition, a subcutaneous implantable defibrillator was inserted for secondary prevention.

This case highlights the importance of identifying indications for CAF closure. Knowledge of available imaging modalities and interventional approaches allows for the productive discussion of treatment options across multiple specialties.