Medicine · 2025
Iatrogenic anastomosis of the internal mammary artery with the great cardiac vein: The first documented case report in Palestine with a literature review.
СтатьяКлинический случайОбзорНазвание и аннотация: Перевод в очереди
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Warasna Haya Jebreen Mohammed, Sabboh Maya, Awad Mohammad Yaser Hasan, Awad Bashar Yaser Hasan, Warasna Ahmad J, Alhadad Baha, Zreqat Qusai N
Аннотация
RATIONALE: An unintentional anastomosis of the left internal mammary artery (LIMA) to the great cardiac vein (GCV) is a rare complication of coronary artery bypass graft surgery (CABG), resulting in a left-to-right arteriovenous shunt. It may cause angina, arrhythmias, or right-sided heart failure, with symptoms sometimes delayed for years. Management varies based on symptoms and hemodynamic impact, ranging from conservative to surgical intervention.
PATIENT CONCERNS: A 60-year-old male presented with recurrent exertional chest pain described as heavy, nonradiating, and relieved by rest. The pain was associated with nausea and sweating. He had a past medical history of ischemic heart disease, chronic obstructive pulmonary disease, hypertension, type 2 diabetes, hyperlipidemia, and a history of supraventricular tachycardia treated with ablation. He was a smoker and had previously undergone CABG in 2020.
DIAGNOSES: Electrocardiography revealed ST-segment depression in leads V4-V6 and T-wave inversion in inferior leads. Troponin was negative. Coronary angiography revealed an iatrogenic LIMA-GCV anastomosis instead of the intended left anterior descending (LAD), along with severe (95%) proximal LAD stenosis and additional mid-LAD disease. Echocardiography showed preserved left ventricular function (ejection fraction 60%).
INTERVENTIONS: The patient underwent percutaneous transluminal coronary angioplasty with drug-eluting stents (Onyx 3.5/18 mm and Xience 2.5/18 mm) to the proximal and mid-LAD segments. No intervention was performed on the nondominant right coronary artery or the LIMA-GCV fistula during this admission.
OUTCOMES: The patient experienced complete resolution of symptoms postintervention. The recovery was uneventful, and he was discharged on the second day of hospitalization.
LESSONS: Iatrogenic aortocoronary arteriovenous fistula is a rare but important complication of CABG, which can lead to significant clinical symptoms. Early diagnosis through coronary angiography is crucial for guiding appropriate management. Although percutaneous intervention with drug-eluting stents effectively resolved the patient's angina by treating the native LAD stenosis, it is critical to recognize that this approach did not address the underlying LIMA-GCV fistula, which requires separate evaluation and management.
PATIENT CONCERNS: A 60-year-old male presented with recurrent exertional chest pain described as heavy, nonradiating, and relieved by rest. The pain was associated with nausea and sweating. He had a past medical history of ischemic heart disease, chronic obstructive pulmonary disease, hypertension, type 2 diabetes, hyperlipidemia, and a history of supraventricular tachycardia treated with ablation. He was a smoker and had previously undergone CABG in 2020.
DIAGNOSES: Electrocardiography revealed ST-segment depression in leads V4-V6 and T-wave inversion in inferior leads. Troponin was negative. Coronary angiography revealed an iatrogenic LIMA-GCV anastomosis instead of the intended left anterior descending (LAD), along with severe (95%) proximal LAD stenosis and additional mid-LAD disease. Echocardiography showed preserved left ventricular function (ejection fraction 60%).
INTERVENTIONS: The patient underwent percutaneous transluminal coronary angioplasty with drug-eluting stents (Onyx 3.5/18 mm and Xience 2.5/18 mm) to the proximal and mid-LAD segments. No intervention was performed on the nondominant right coronary artery or the LIMA-GCV fistula during this admission.
OUTCOMES: The patient experienced complete resolution of symptoms postintervention. The recovery was uneventful, and he was discharged on the second day of hospitalization.
LESSONS: Iatrogenic aortocoronary arteriovenous fistula is a rare but important complication of CABG, which can lead to significant clinical symptoms. Early diagnosis through coronary angiography is crucial for guiding appropriate management. Although percutaneous intervention with drug-eluting stents effectively resolved the patient's angina by treating the native LAD stenosis, it is critical to recognize that this approach did not address the underlying LIMA-GCV fistula, which requires separate evaluation and management.