Cardiac CT Planning of Surgical Treatment of Multiple Coronary-Pulmonary Fistulas With Chronic Coronary Occlusion.

ANATOMY: Coronary fistulas are rare congenital anomalies that may lead to myocardial ischemia through a coronary steal phenomenon, particularly when associated with coronary artery disease. PATHOLOGY: We describe a case of cardiac computed tomography angiography (CCTA) diagnosis of multiple coronary-pulmonary artery fistulas associated with chronic occlusion of the right coronary artery, in a 66-year-old man presenting with unstable angina. IMAGING CORRELATION: CCTA and echocardiography were used for evaluation of procedural planning in an acute setting. TREATMENT: The fistulas were effectively treated with surgical exclusion combined with coronary artery bypass grafting, yielding an optimal result on the postoperative computed tomography scan. TAKE-HOME MESSAGES: Coronary fistulas are rare but important causes of myocardial ischemia. This case highlights the importance of CCTA definition of anatomical complexity and multidisciplinary decision-making in the management of complex coronary fistulas. Surgical repair remains the preferred approach in complex anatomy cases or associated coronary artery disease requiring revascularization.