Bilateral Coronary Artery–to–Pulmonary Artery Fistula Treated Using Minimally Invasive Coils and Vascular Embolization Devices

BACKGROUND: Coronary artery-to-pulmonary artery fistula (CAPF) is a rare condition that is often asymptomatic; however, intervention is indicated in symptomatic patients or in those with myocardial ischemia. CASE SUMMARY: A 44-year-old woman with a cardiac murmur since early adulthood presented with progressive exertional dyspnea. Cardiac computed tomography revealed bilateral plexus-like CAPF with aneurysmal formation. Although the Qp/Qs ratio was 1.08, stress cardiac magnetic resonance imaging demonstrated myocardial ischemia. Pulmonary artery-side outflow embolization was performed using a vascular occlusion device, followed by coil embolization of the coronary artery-side inflow sites, resulting in resolution of symptoms and improvement of ischemia. DISCUSSION: Although pulmonary artery-side embolization can be effective when fistulous drainage converges into a single site, intercommunication between bilateral fistulas may elicit to-and-fro flow and compromise coronary perfusion. TAKE-HOME MESSAGE: In plexus-like CAPFs with intercommunication, combined pulmonary artery outflow and coronary artery inflow embolization should be considered according to vascular morphology.