[A case of percutaneous closure of a complex coronary artery fistula]

Coronary artery fistulas (CAFs) are rare coronary anomalies defined as abnormal direct communications between a coronary artery and a cardiac chamber or great vessel. We report the case of a 66-year-old man admitted for left ventricular dysfunction (ejection fraction 40%) caused by a large, complex septal coronary artery fistula draining into the pulmonary artery, associated with a critical mid-left anterior descending artery (LAD) stenosis. Multimodal imaging (coronary angiography, coronary computed tomography, and dobutamine stress echocardiography) confirmed significant coronary steal and complex anatomical features. A sequential percutaneous approach was performed: first, fistula occlusion was achieved by deploying 15 coils via a microcatheter; subsequently, a drug-eluting stent was implanted in the mid-LAD. Final intravascular ultrasound confirmed adequate stent expansion and angiography complete fistula exclusion. The patient was discharged asymptomatic on dual antiplatelet therapy. At 3-month follow-up, an improvement of left ventricular ejection fraction was observed. This case demonstrates the feasibility of an entirely percutaneous strategy (coiling and stenting) in the management of complex coronary fistulas with multiple aneurysms and concomitant coronary artery disease.