Abstract 15837: Anomalous Bronchial Artery Origin- The Canary in the Coal Mine- For the Diagnosis of Chronic Thromboembolic Pulmonary Hypertension

Abstract

Introduction- Anomalous bronchial artery origin is seen in 8.3% to 35% of cases with most originating from the aortic arch, internal mammary artery, and subclavian artery. Origin of this vessel from a coronary artery is extremely rare. Case presentation- A 49-year-old male with history of unprovoked pulmonary embolisms (PE) in the setting of triple antibody positive Antiphospholipid antibody syndrome on lifelong anticoagulation presented with left sided chest pain and dyspnea. Initial lab work showed a troponin of 5.46 ng/mL, BNP of 602 pg/mL and D-dimer of 0.62 ug/mL. EKG showed normal sinus rhythm with non-specific ST segment changes in anterior leads. Computed Tomography Angiography (CTA) was positive for a PE. There was concern for a false positive result due to previous history of multiple PEs while on therapeutic levels of warfarin and near normal D-dimer. Echocardiogram showed ejection fraction of 38% with akinesis of anteroapical and inferoapical segments and no evidence of shunt on bubble study. Cardiac catheterization showed non-obstructive coronaries. From the ostium of the right coronary artery there appeared a fistula like structure extending into the pulmonary vasculature. Pulmonary angiogram was performed and showed chronic occlusion in branches of right pulmonary artery (RPA), pulmonary hypertension (PH) with mean pulmonary artery pressure of 36 mmHg and no evidence of acute thrombus. There was aberrant origin of the right bronchial artery from the right coronary artery that was hypertrophied as it supplied collateral flow to the area of the occluded RPA. The patient was started on guideline directed medical therapy for heart failure and follow up was arranged for further outpatient management of PH. Discussion- A rare congenital anomaly was used to guide the diagnosis of a potentially devastating and treatable medical condition. It shows the limitations of a CTA in the setting of chronic PE.