Abstract 15772: From Agony to Relief: Overcoming Angina Through Endovascular Coiling of the Left Internal Mammary Artery (LIMA) to Pulmonary Artery (PA) Fistulae- A Case Report

Abstract

Introduction: LIMA to PA fistulae are a rare complication after coronary artery bypass graft (CABG) surgery. We present a patient with angina secondary to a steal syndrome from LIMA-PA fistulae, treated with endovascular coiling. Case: The patient is a 49-year-old active male with coronary artery disease, status post CABG at age 46 with a LIMA graft to the left anterior descending artery, radial artery graft to the first obtuse marginal artery, and saphenous venous graft (SVG) to the posterior descending artery. At age 48, he developed angina and underwent stent placement to the distal right coronary artery after the SVG was found to be occluded. Several months later, he reported dyspnea and chest pain on exertion. An exercise nuclear stress test showed abnormal myocardial perfusion in the anteroseptal region, and he was referred for left heart catheterization (LHC). LHC revealed unchanged native coronary disease, patent LIMA, and a network of collateral vessels from the LIMA feeding into the pulmonary vasculature (Figure 1). The collaterals were not seen on LHC 9 months prior. CT coronary angiography confirmed multiple fistulae originating from the superior aspect of the LIMA graft communicating with the PA (Figure 1). After a multidisciplinary, patient-centered, heart team discussion, he underwent successful endovascular coiling of the collateral branches (Figure 2). Discussion: LIMA-PA fistulae is a rare cause of angina and there is a paucity of literature on management. To our knowledge, coil embolization has been described in roughly 10 cases. Here, we present a successful case of endovascular coiling of collateral vessels leading to symptomatic improvement.