Bilateral Fistulas Research Articles

Bilateral Orocutaneous Fistula Secondary to Pericoronal Infection of Mandibular Third Molars: A Rare Case Report.

Odontogenic cutaneous fistulas are abnormal connections between the oral cavity and skin, often mistaken for skin infections. They typically result from dental infections but may also arise from salivary gland issues, tumors, or congenital anomalies. Accurate diagnosis is essential to prevent complications like infection, osteomyelitis, and discomfort. A 26-year-old woman presented with bilateral facial lesions and itching for the past year. Her symptoms began 5 years earlier with cheek pain and swelling, initially treated with antibiotics. Examination revealed pericoronitis of the mandibular third molars, leading to bilateral orocutaneous fistulas. Surgical removal of the affected teeth and fistulas was performed. Orocutaneous fistulas commonly result from long-standing dental infections. Their location depends on the perforation site of the cortical plate. Early diagnosis through clinical examination and imaging is vital to prevent severe complications like osteomyelitis. Treatment involves addressing the underlying cause, typically through root canal therapy or tooth extraction. This case highlights the importance of early, interdisciplinary management of orocutaneous fistulas to prevent misdiagnosis, reduce discomfort, and avoid complications. Timely treatment ensures better outcomes and minimizes cosmetic concerns.

Minimally Invasive Endovascular Treatment of Bilateral Indirect Carotid-Cavernous Fistula.

Minimally Invasive Endovascular Treatment of Bilateral Indirect Carotid-Cavernous Fistula.

Sural-to-medial femoral cutaneous amplitude ratio in early diagnosis of uremic neuropathy.

Medial femoral cutaneous (MFC) sensory nerve action potentials (SNAPs) can be easily recorded using distal stimulation. This study aimed to identify a new parameter using MFC SNAPs for the early electrophysiological diagnosis of length-dependent axonal polyneuropathy (LDAP) associated with uremic neuropathy. Patients with chronic renal failure who were referred to the electrodiagnostic laboratory due to symptoms suggesting polyneuropathy were included. Assessments encompassed neurological examination, Michigan Neuropathy Screening Instrument (MNSI), and Semmes-Weinstein monofilament test. Antidromic radial, median, ulnar, MFC, sural, and superficial peroneal sensory; median, ulnar, tibial, and peroneal motor nerve conduction studies were performed. Sural-to-radial amplitude ratio (SRAR) and sural-to-medial femoral cutaneous amplitude ratio (SMFCAR) were calculated, and their diagnostic sensitivities were compared with the age and sex matched healthy controls. Thirty-two chronic renal failure patients (mean age 60.0 ± 9.6 years) and 37 controls (60.6 ± 9 years) were included. MNSI indicated clinical polyneuropathy in 59.4% of patients, while sural SNAP amplitude was diagnostic in 78%. Median SRAR and SMFCAR values were significantly lower in patients than controls (p < .001 for both). The cut-off values for SMFCAR and SRAR were <1.82 and <0.30, respectively, both with a sensitivity of 59% and a specificity of 94%. Sural SNAP is the most sensitive parameter in the diagnosis of LDAP. SMFCAR is not superior to SRAR. If the sural SNAP amplitude is normal, SMFCAR can serve as an alternative to SRAR in dialysis patients with bilateral arteriovenous fistulae or in those unable to undergo radial NCS.

Treacher Collins Syndrome 2 caused by a novel pathogenic variant in PLOR1D: clinical report and literature review

Objective: To investigate the clinical features, molecular etiology, and treatment of a family with Treacher Collins Syndrome 2 (TCS2). Methods: Information of the proband (female, 8 years old) including medical history and family history was collected. Physical examination and examinations concerning laboratory, audiology, and radiology were performed on the proband. Physical examination was also performed on the family members. Genomic DNA of proband was extracted for whole exome sequencing, and then the genomic DNA of family members was extracted for Sanger sequencing. POLR1D and TCS2 related literatures published before August 31,2023 were searched and sifted in PubMed and CKNI databases. The clinical characteristics of TCS2 were summarized. Results: The proband had poor hearing since childhood, with pure tone audiometry indicating conductive hearing loss. She had a smaller jaw, bilateral preauricular fistulas and cup-shaped ear deformities. Temporal bone CT scan revealed deformities in the left external ear canal, bilateral middle ear and inner ear. A bone-conduction hearing aid device was surgically implanted, resulting in restoration of almost normal hearing levels. The proband's mother also had a slightly smaller jaw. Genetic analysis revealed a novel heterozygous variant NM_015972.4:c.38_47del in the POLR1D gene in the proband, which was inherited from her mother. A review of the literature revealed no clear evidence of genotype-phenotype correlation in TCS2. Conclusions: Molecular diagnosis plays a vital role in the diagnosis of TCS2. Patients with normal facial phenotype may be carriers of pathogenic variants in the POLR1D gene and have the risk of passing it to the offsprings with complete penetrance. Proper bone conductive hearing devices can improve the quality of life of TCS2 patients.

Clinical phenotypic and genetic analysis of syndrome families with EYA1 gene variants

Objective:To investigate the clinical phenotype of a family with branchio-oto syndrome （BOS） and to explore the genetic etiology of the syndrome in this family. Methods:Clinical data were collected from a child diagnosed with BOS and his family members. Genomic DNA was extracted from peripheral blood of the proband and his family members. Whole-exome sequencing was performed, and the mutation sites were verified and analyzed by Sanger sequencing. Results:The family consists of two generations with four members, three of whom exhibit the phenotype. Two members have hearing loss and bilateral preauricular fistulas and bilateral branchial cleft fistulas. One member has bilateral preauricular fistulas and bilateral branchial cleft fistulas. All of which were in line with the clinical diagnosis of gill ear syndrome, the inheritance mode of the family was autosomal dominant inheritance, genetic testing showed that all members of the family had c. 1744delC（p. L592Cfs*47） mutation in the EYA1 gene, while unaffected members have the wild-type allele at this locus. This mutation is a frameshift mutation, which results in the early appearance of the stop codon, and has not been reported so far. According to ACMG guidelines, the variant was preliminarily determined to be suspected pathogenic. Conclusion:The newly discovered EYA1c. 1744delC（p. L592Cfs*47） mutation in this family is the pathogenic mutant gene of the patients in this family, which further expands the mutation spectrum of EYA1 gene, gives us a new understanding of the disease, and provides an important reference for clinical diagnosis and genetic counseling.

Abdominal hysterectomy due to uterine rupture causing bilateral ureterovaginal fistula: A rare case report

Abstract Ureterovaginal fistula (UVF) is defined as abnormal communication between ureter and vagina. Although documented after radical hysterectomy, post radiation and retained pessary incidence of bilateral UVF is still very rare. We have documented a case report of a multipara woman presented with persistent urinary leakage following an emergency hysterectomy for obstructed labor. After evaluation with imaging there was bilateral hydroureterophrosis with dense purulent collection mixed with contrast in the vesicular area with lower end of ureter draining in the vaginal vault with preserved renal function. During exploration both ureters were dilated. Instillation dye in both ureters showed extravasation in vagina. After ligating distal ends modified Lich-Gregoir technique done over double J (DJ) stents. DJ removed after 3 months. Bilateral UVF is only 5%–10% of all ureteric injury. Aggressive blind clamping, excessive hemorrhage, distorted anatomy, malignancy and surgeons experience play a crucial role. Obstetric cause is the prime factor. Preventing measures like proper screening of antenatal patients, early detection of high-risk pregnancy, supervised caesarean section should be taken to avoid ureteric injuries

Interventional Embolization of Unilateral Cavernous Sinus With ONXY Glue Combined With Coils for the Treatment of Bilateral Dural Arteriovenous Fistula.

To summarize the clinical experience of unilateral sponge sinus embolization of cavernous sinus dural arteriovenous fistula (CS DAVF) via jugular vein access with ONXY gel and spring coil intervention. The authors retrospectively analyzed the clinical data of 3 patients who were treated with unilateral cavernous sinus embolization for bilateral cavernous sinus dural arteriovenous fistula (CS DAVF) from October 2020 to May 2022 in our department by using transjugular vein access spring coil + ONXY gel interventional embolization. Immediate postoperative angiography suggested that the cavernous sinus fistula was completely embolized in all 3 patients, and cerebral angiography was carried out from 6 to 12 months after the operation and assessed using the Class grading method, and there was no recurrence in any of the 3 patients. Transvenous access ONXY adhesive combined with spring coil interventional embolization of unilateral cavernous sinus to cure bilateral cavernous sinus dural arteriovenous fistula is feasible, which can avoid the excessive use of spring coils and ONXY adhesive, and it is the key to the effective cure of DAVF in cavernous sinus area and to reduce the complication.

A Rare Case of Bilateral Second Arch Branchial Fistulae; A Case Report.

Branchial arch anomalies are considered congenital defects that can occur during fetal development. They may present as cysts, sinuses, or fistulae. Anomalies of the second branchial arch are the most common. The existence of bilateral complete fistulae is exceptionally rare. In this case report, a 5-year-old boy presented with recurrent episodes of bilateral neck swelling and watery discharge from openings on the anterolateral sides of his neck since birth. He was diagnosed with bilateral branchial fistulae after confirmation via a contrast-enhanced CT scan. Surgery was performed to entirely excise the fistula tracts bilaterally. Additionally, a bilateral tonsillectomy was performed to help prevent recurrence.

Laparoscopic uterine preservation and vaginal reconstruction in a patient with uterus didelphys, vaginal agenesis and bilateral vesicoavginal fistulas

Laparoscopic uterine preservation and vaginal reconstruction in a patient with uterus didelphys, vaginal agenesis and bilateral vesicoavginal fistulas

An Innovative Therapy by Changing the Gut Microbiome for the Dual Post-Operative Complications of the Recurrent Methicillin-Resistant Staphylococcus aureus (MRSA) Infections in the Residual Type II First Branchial Cyst and Facial Nerve Palsy

A very unusual, interesting, and challenging case of a 24-year-old female who was born with three openings in the neck. The patient had chronic abdominal gaseous distention, recurrent abdominal pain, and constipation since early infancy. The patient presented in emergency with acute painful red, hot, and tender swelling in the left upper cervical area. Laboratory studies showed high inflammatory markers and a provisional diagnosis of abscess with a sinus was made. The patient underwent an emergency incision and drainage. Sinus recurred and a sinogram showed it to be a residual cyst in the left submandibular salivary gland. The total cyst excision was attempted with resultant recurrence and grade IV facial nerve palsy. Post-operatively recurrent infections caused by Methicillin-resistant Staphylococcus aureus (MRSA) required several courses of oral and intravenous broad-spectrum antibiotics with several hospital admissions with no resolution in sight. Subsequent ultrasound and magnetic resonance imaging showed a residual infected cyst, cutaneous sinus, and a fistula opening in the left ear canal. A diagnosis of branchial cyst type II of the first brachial cleft remnant with a fistula was established with bilateral branchial fistulas of the second branchial remnants and the associated colorectal hypoganglionosis based on radiological studies. The patient refused any further operative interventions. Therefore, the option of conservative treatment of hypoganglionosis with holobiotics consisting of prebiotics, probiotics and postbiotics, laxatives, dietary changes, lifestyle modifications, and dietary supplements started. All antibiotics were stopped. These therapies resulted in the resolution of residual first branchial remnants and recurrent MRSA infections with the improvement in the facial nerve palsy from grade IV to grade III-IV together with an excellent cosmetic and functional result. The patient is doing well at follow-ups being infection-free for 18 months and repeat contrast-enhanced computed tomogram (CECT) has shown complete resolution of the residual cyst, sinus, and fistula with fibrosis.

Attention to pulmonary arteriovenous fistula in a case of transient hypoxemia and cerebral infarction during pregnancy: a case report and literature review

BackgroundPulmonary arteriovenous fistula is rare during pregnancy. Pulmonary arteriovenous fistula presents no pulmonary symptoms in most patients but can be exacerbated by pregnancy. If not diagnosed and treated promptly, pulmonary arteriovenous fistula can lead to respiratory failure, stroke, spontaneous hemothorax, or other fatal complications.Case presentationA 29-year-old healthy pregnant woman presented with a transient drop in blood oxygen level of unknown cause during a routine examination at 34 weeks of gestation and during a cesarean section at 38 weeks of pregnancy. The patient’s oxygen saturation quickly returned to normal and was not further investigated. On day 3 postpartum, the patient suddenly displayed slurred speech and right limb myasthenia. A head magnetic resonance imaging revealed cerebral infarction in the left basal ganglia. Subsequent computed tomography pulmonary arteriography revealed bilateral pulmonary arteriovenous fistula, which was likely the cause of cerebral infarction. The patient was transferred to the Department of Thoracic Surgery after one month of treatment and successfully underwent percutaneous embolization of pulmonary arteriovenous fistula.ConclusionPulmonary arteriovenous fistula should not be neglected if a pregnant woman presents with transient hypoxemia and cerebral infarction. A transient decrease in pulse oxygen saturation that cannot be explained by common clinical causes can be an early warning sign of the disease. Early diagnosis and multidisciplinary management could improve the prognosis.

Endovascular treatment in bilateral cavernous sinus dural arteriovenous fistulas: a systematic review and meta-analysis

Few studies have discussed the disease nature and treatment outcomes for bilateral cavernous sinus dural arteriovenous fistula (CSDAVF). This study aimed to investigate the clinical features and treatment outcomes of bilateral CSDAVF. Embase, Medline, and Cochrane library were searched for studies that specified the outcomes of bilateral CSDAVF from inception to April 2022. The classification, clinical presentation, angiographic feature, surgical approach, and treatment outcomes were collected. Meta-analysis was performed using the random effects model. Eight studies reporting 97 patients were included. The clinical presentation was mainly orbital (n = 80), cavernous (n = 52) and cerebral (n = 5) symptoms. The most approached surgical route was inferior petrosal sinus (n = 80), followed by superior orbital vein (n = 10), and alternative approach (n = 7). Clinical symptoms of 88% of the patients (95% CI 80–93%, I2 = 0%) were cured, and 82% (95% CI 70–90%, I2 = 7%) had angiographic complete obliteration of fistulas during follow up. The overall complication rate was 18% (95% CI 11–27%, I2 = 0%). Therefore, endovascular treatment is an effective treatment for bilateral CSDAVF regarding clinical or angiographic outcomes. However, detailed evaluation of preoperative images and comprehensive surgical planning of the approach route are mandatory owing to complexity of the lesions.

Spontaneous Bilateral Lumbar Region Colocutaneous Fistulae. A Case Report

Bilateral spontaneous lumbar colocutaneous fistulae are rare. They are associated with high costs of care, morbidity, and mortality. We present the case of a 50- year-old male patient who presented with a 10-year history of two low-output spontaneous colocutaneous fistulae from both the left and right lower lumbar regions with no identifiable risk factors. He was managed operatively with segmental left colon resection and a temporary loop ileostomy with uneventful recovery after reversal of the ileostomy 2 months later. Whether the etiology of the fistulae is clinically apparent or not, the management should follow commonly known principles. This report highlights a case of bilateral lumbar region spontaneous colocutaneous fistulae of unknown cause that was managed operatively with satisfactory short-term outcomes.

Cocaine Orbitopathy Complicated by Orbital Wall Defects, Bilateral Naso-Orbital Fistulas, Phthisis, and Bilateral Vision Loss.

A 64-year-old male with a 40-year history of daily intranasal cocaine use presented with painless, gradually worsening binocular diplopia. External examination showed a severe saddle-nose deformity. Ophthalmologic exam was notable for visual acuity of 20/40 in OU, with restrictive strabismus, esotropia, and hypotropia in the OD. Neuroimaging revealed extensive nasal septal destruction with erosion of bilateral medial and orbital floors. The patient was lost to follow-up and presented 3 years later with progression of vision loss, now light perception vision OD and count fingers vision OS. There was now complete absence of the nasal bridge and medial orbital walls with large naso-orbital fistulas bilaterally, and phthisis of the right globe with complete corneal neovascularization. Laboratory work-up, including perinuclear anti-neutrophil cytoplasmic antibodies, cytoplasmic anti-neutrophil cytoplasmic antibody, erythrocyte sedementation rate, c-reactive protein, and chest X-ray, were unremarkable. The patient continually refused drug testing. Repeat neuroimaging revealed progression of the nasal midline destruction and further loss of the medial and orbital floors (panels A and B). These findings were consistent with anatomic destruction of the orbital bony walls and subsequent ocular necrosis, perforation, and ischemia related to long-term cocaine use (panel C). Cocaine use can result in tissue damage through its alpha agonist and inflammatory properties leading to a prothrombotic state, vasoconstriction, and subsequent ischemia. The authors present a severe case of presumed cocaine orbitopathy resulting in extensive midline structural loss, destruction of the medial and inferior orbital walls, naso-orbital fistulas, and subsequent phthisis bulbi resulting in vision loss.

Complete Second Branchial Cleft Fistulas: A Clinicosurgical Experience.

A complete second branchial fistula is very rare and has an internal opening at the tonsillar fossa and an external opening at the lower third of the sternocleidomastoid (SCM). Patients commonly present with persistent or intermittent mucoid or mucopurulent discharge from an external opening. The diagnosis is most often clinical and radiological investigations are rarely needed. Treatment of choice is complete surgical excision. The aim of this article is to aware young ENT surgeons of the various clinical and intraoperative surgical findings that can be encountered while dealing with these cases. This observational study was done for a period of 10years. A total of 20 cases of fistula were included which intraoperatively had a complete track from tonsillar fossa to neck. Excision of the tract was carried out via combined transcervical and transoral approach under general anaesthesia using two incisions in stepladder pattern. Each patient was seen after one year of surgery to assess for any recurrence. Different findings of patients including age/sex at surgery, initial presentation, family history, laterality of the fistula tract, Intraoperative surgical findings, complications, and recurrences. were noted. Of the 20 patients, 13 (65%) were females and 7 (35%) were Females. Most common complaint was fistulous opening with intermittent discharge(15patients; 75%).Branchial cleft fistulae more commonly affected the right neck (14 patients, 78%) among unilateral cases and 2 patients (10%) had bilateral fistulae. No patient had associated congenital anomaly/syndrome, family history or and visible opening in tonsillar area. Glossopharyngeal nerve was identified in 12 cases and track was seen passing lateral to it except in one case. The internal opening of track was seen over posterior tonsillar pillar in 15 cases (75%) while in 5 patient the track was seen entering tonsillar tissue or bed. Tonsillectomy was done in 5 cases while not done in 15 cases where track was seen entering posterior pillar. All patients were seen at one year follow up. No recurrence was seen at one year of follow up. Complete second branchial cleft fistulae are rare. They are usually right sided and unilateral. The track passes between carotid bifurcation and invariably passes lateral to both glossopharyngeal and hypoglossal nerves. Track usually ends at the posterior tonsillar pillar. Tonsillectomy is not routinely indicated. Recurrences are not typically seen.

A Case with Bilateral Dural Arteriovenous Fistulae Manifesting as Sequential Trochlear, Oculomotor Nerve Palsies

Purpose: We report a patient with bilateral dural arteriovenous fistulae (DAVF) who initially presented with unilateral, isolated trochlear nerve palsy; and later with contralateral, oculomotor nerve palsy.Case summary: A 72-year-old male without any underlying disease or a trauma history visited with sudden vertical diplopia in both eyes that had developed 5 days prior. Brain magnetic resonance imaging (MRI) performed before his first visit was unremarkable. The eye movement test revealed hyperdeviation and limitation of downgaze in the left eye; we thus suspected unilateral, ischemic trochlear nerve palsy and this was indeed observed. However, the diplopia did not improve and limitations of the upper, medial gaze of the right eye developed after 3 months. Follow-up examinations (orbital computed tomography, brain MRI, and cerebral angiography) revealed bilateral DAVF running from the left to the right. He underwent gamma-knife radiosurgery; then the eye movement limitations and diplopia improved.Conclusions: Diplopia manifesting as paralysis in an elderly patient may be caused by DAVF; the diplopia may not always be the common ischemic paralytic strabismus. DAVF should be considered during differential diagnosis and further radiological examinations may be needed.

Initial Experience of A New Technique for Sphincter Preserving Anal Fistula Repair Using a Radial Emitting Laser Probe

Background: Fistula in ano has been a troublesome pathology to both patients and surgeons throughout surgical history. Several techniques have been described for the management of fistula-in-ano but all carry their own risks of recurrence and incontinence. To overcome this problem, a novel technique called distal laser and proximal ligation (DLPL) was developed using a newly invented radial emitting laser probe. This study is aimed to see the outcome in terms of recurrence and incontinence of newly described technique. Materials and methods: This prospective study was conducted in a single private institute in The Dhaka city between January 2018 and July 2019. All patients with fistula in ano of cryptoglandular origin are included in this study and evaluated in outpatient department. Fistulogram done beforehand only those with recurrent fistula tract. Patients having fistula with chron’s disease, abscess cavity, side tract or malignancy were excluded from this study. A total of fifty two (52) male patients were selected. All patients were followed up and Results were evaluated. Results: The median age of the patients was 46 years (range 22-60 years), 39 patients were primary fistula, 9 patients were recurrent fistula with history of previous fistula surgery and 4 patients were bilateral anal fistula. All patients underwent DLPL (distal laser proximal ligation) operation by radial emitting Laser probe. The mean follow up was 11 months (range 6-24 months). Forty three out of 52 fistulas showed primary healing (82.6 %) without any problem of anal incontinence. Only 6 patients developed recurrent fistula (11.53%) within 3 months of Surgery. Conclusion: The use of a diode laser source and a radial emitting laser probe in addition to conventional surgery in treating different types of anal fistula for selected group of patients is a very promising new technique in sphincterpreserving anal fistula repair. J Bangladesh Coll Phys Surg 2022; 40: 153-158

Difficulties in Diagnosis and Surgical Treatment of Bilateral Pancreaticopleural Fistula

The study presented clinical observation of a patient with a rare complication of chronic pancreatitis - a formed bilateral pancreaticopleural fistula. The clinical picture of the disease was similar to that of recurrent bilateral hydrothorax. To specify the diagnosis, it was necessary to perform a pleural puncture with a biochemical analysis of the removed pleural fluid. A high level of pancreatic amylase in the pleural fluid, results of targeted multislice computed tomography of the pancreas with contrast and magnetic resonance cholangiopancreatography revealed a bilateral pancreaticopleural fistula. Distal resection of the pancreas proved to be an effective and sufficient radical surgical intervention, which provided reliable elimination of the pancreaticopleural fistula and bilateral enzymatic pleurisy.

Salvaged, Staged, and Safer Management of Aortoesophageal Fistula and Mediastinitis After Removing a Pork Bone: A Case Report

Aortoesophageal fistula (AEF) caused by esophageal foreign body (EFB) ingestion is a life-threatening condition with a very low survival rate. However, the optimal management strategy remains undetermined. Here, we describe our successful management of a patient with AEF and mediastinitis. A 36-year-old man developed persistent chest and back pain and vomited fresh blood three days after removal of a pork bone in the esophagus under endoscopy in a local hospital. Computed tomography (CT) confirmed bilateral pulmonary infections, mediastinitis, and fistula of the aortic arch. After a multidiscipline discussion, a comprehensive staged strategy was made including salvaged thoracic endovascular aortic repair (TEVAR) to control fatal bleeding, adequate mediastinal debridement, drainage with cervical incision, and video-assisted thoracoscopic surgery, as well as jejunostomy to prevent nasal or gastrostomy reflux from aggravating the mediastinal infection. Furthermore, systematic personalized nutrition support and antibiotics were provided. The patient recovered well and has survived for 50 months until now. Careful assessment should be made with CT to ascertain the risk of AEF before and after the removal of EFB. A salvaged staged strategy of TEVAR with adequate mediastinal debridement and drainage in a less invasive approach may be a safer alternative for AEF patients with infections caused by EFB.

Prevalence and characteristics of coronary artery fistula in adults: coronary angiographic analysis of 18,106 patients.

Aim Coronary artery fistula (CAF) is a rarely encountered anomaly that is characterized by an abnormal connection between a coronary artery and a cardiac chamber or a great thoracic vessel. Its incidence has not been precisely established due to the large number of undiagnosed cases and it shows heterogeneity in its anatomic configuration and clinical consequences. We aimed to assess the frequency, imaging findings, and clinical features of CAF among patients in our tertiary medical center.Material and methods The angiographic data of 18,106 consecutive adult patients who underwent coronary angiography between January 2011 and June 2013 were retrospectively analyzed.Results CAF was detected in 22 patients (0.14 %). Of these, 5 patients had bilateral fistulas (23 %). 65 % of the fistulas originated from the left anterior descending coronary artery,and 53 % drained into the pulmonary artery. The left ventricle and left atrium were the only drainage sites for left-sided coronary artery fistulas. One patient with a CAF presented with non-ST elevated myocardial infarction in the absence of an evident thrombosis.Conclusion Unlike previous reports, bilateral CAFs were more commonly encountered in this study. Contrary to most of the data in the literature, more than half of the CAFs originated from the left anterior descending coronary artery and most drained into the pulmonary artery. Rare anatomic types of CAFs were also detected.