Fistulous Connection Research Articles

Ventriculocoronary fistulae in a patient with transposition of the great arteries, hypoplastic left heart, and pulmonary atresia

We present a rare case of ventriculocoronary fistulae in a patient with d-transposition of the great arteries, hypoplastic left heart, and pulmonary atresia. To our knowledge, this is the first report of this anatomic variant, and raises an important discussion about the development and implications of such fistulous connections.

Cervical Branchial Cartilaginous Remnant

Failure of proper migration, fusion, or maturation of the branchial apparatus components results in a variety of congenital defects. Most branchial cysts and fistulae are considered to be derived from the first and second branchial clefts. Of these, cervical cartilaginous rests are infrequent, whereas branchial cysts and sinuses are relatively more common. Our patient, a 4-year-old girl, had been operated on with simple skin excision and excision of the combined platysma. Finding from histopathology revealed a hyaline cartilage. Cervical branchial remnants do not have fistulous tracts or connections with important deeper organs; hence, they can be safely transected at the level of the superficial musculature. Therefore, we believe that the most important points are optimal incision for branchial cartilaginous remnants and surgical excision with preservation of the normal anatomy.

Pancreatic-pleural fistula in chronic pancreatitis

Pancreatic-pleural fistula is a rare condition and few data related to its diagnosis and treatment are available. A fistulous connection linking the pancreas with the pleura via the diaphragm or mediastinum through the retroperitoneal area is formed.We report on a case with pancreatic-pleural fistula at its early stages in an alcoholic male patient aged 45years with known chronic pancreatitis. The operation by Roux-en-Y jejuno-pseudocystostomy was followed by chest tube drainage.

Aorto‐Right Atrial Fistula Following Transseptal Catheterization and Catheter Ablation for Atrial Fibrillation

Aorto-cameral fistula, either congenital or acquired, is an abnormal connection between the ascending aortic root and one of the cardiac chambers. We report a case of a 61-year-old male with history of atrial fibrillation and 2 radiofrequency ablation procedures, referred to us for surgical Cox Maze procedure. Preoperative cardiac computerized tomography revealed a fistulous connection between the aortic root and the right atrium. Later, the patient underwent successful surgical closure of the fistula during the Cox Maze procedure. In this paper, we also discuss the clinical presentation, natural history, anatomy of the interatrial septum, and management of aorto-cameral fistula.

Empyema and Respiratory Failure Secondary to Nephropleural Fistula Caused by Chronic Urinary Tract Infection: A Case Report

We report a case of nephropleural fistula causing empyema and respiratory failure in a 68-year-old gentleman with a long history of urological problems including recurrent nephrolithiasis and urinary tract infections. He was admitted with sepsis, a productive cough, pyuria, and reduced breath sounds over the left hemithorax. Radiological imaging revealed a fistulous connection between a left-sided perinephric abscess and the pleural space. He was commenced on broad spectrum intravenous antibiotics but developed progressive respiratory failure requiring intensive care admission. Urinary and pleural aspirates cultured facultative anaerobic pathogens with identical resistance patterns. Drainage of thoracic and perinephric collections was carried out, allowing him to be extubated after 24 hours and discharged home after 18 days on an extended course of oral antibiotics. Left nephrectomy is now planned after a period of convalescence. Empyema developing in patients with known urolithiasis should alert the treating physician to the possibility that a pathological communication has formed especially if typical urinary tract pathogens are cultured from respiratory sampling.

Posttracheostomy tracheoesophageal fistula

A 47-year-old diabetic and hypertensive woman was hospitalized with respiratory distress and right hemiparesis following a stroke. Magnetic resonance imaging (MRI) revealed right cerebellar and medullary infarcts. She was put on ventilator support, and anticipating prolonged ventilation, a tracheostomy was done. Multiple complications further extended her ventilation; her tracheostomy and nasogastric tubes were eventually removed after 5 months. At this time she was conscious, though weak, with normal hemodynamics and respiration. However, the patient continued to have episodes of respiratory distress and hypoxia and had to be reventilated twice; her chest X- ray also showed pneumonic patches in the left middle and lower lung zones. We noticed that each time oral feeding was initiated the patient would cough vigorously and complain of breathing difficulty. She was apprehensive of eating, drinking, and even swallowing her saliva, which she would frequently spit out. Possibility of a tracheoesophageal fistula (TEF) was considered. A barium swallow confirmed the presence of a fistulous connection between the left bronchus and esophagus at T-4 level [Figure 1]. Esophagoscopy however failed to demonstrate the TEF, which was probably small-sized. The patient was nursed semiupright, oral feeding was stopped, and small enteral feeds through a nasogastric tube started; she had no more respiratory problems and her condition gradually stabilized. Definitive management of the TEF was deferred to allow time for spontaneous fistula closure and to build up her nutrition; she was discharged on request and advised to return for a review after a month. However, she did not report back and was lost to further follow-up.Figure 1: Barium-swallow with a water soluble contrast showing selective opacification of the left lower lobe bronchus (arrow) suggestive of a tracheoesophageal fistulaTEF is a rare but serious complication of tracheostomy (incidence ≤ 1%)[1] caused by mucosal ischemia/abrasion secondary to prolonged intubation, use of high cuff pressures (≥ 30 cm H2O) and movement of the tube tip during frequent dressing changes and suctioning; concomitant use of a rigid, wide-bore nasogastric tube aggravates injury of the sandwiched mucosa.[2] Poor nutrition, airway infection, hypotension, hypoxemia, anemia, diabetes, and steroid therapy are the predisposing factors. TEFs secondary to tracheal cuff related injuries usually become symptomatic within 4 weeks.[2] Usual manifestations in nonventilated patients include uncontrolled coughing after swallowing (Ono's sign), breathing difficulty, repeated pneumonia, and unexplained weight loss.[3] A barium swallow demonstrates the defect in 70% of lesions. Endoscopy is the best diagnostic method, though small TEFs may be missed in the esophageal folds; bronchoscopy with methylene blue instillation identifies the defect better. Computed tomography (CT) and MRI chest are preferred in ventilator-dependent patients; chest X-ray demonstrates the effects of repeated soiling. Management of a TEF includes supportive therapy to improve the patient's condition followed by definitive intervention. While smaller fistulae may heal spontaneously, large TEFs are treated surgically with a single-staged fistula repair, or with tracheal reconstruction. Patients incapable of tolerating surgery are managed with esophageal or double (tracheal and esophageal) stenting using self-expanding metallic stents.[24] Close monitoring of the cuff pressure and volume (avoid pressure ≥ 20 cmH2O and volume ≥ 6–8 ml) can help reduce the risk of tracheal injury. Deflating the cuff every few hours does not decrease injury but may increase the risk of aspiration.[5] Our patient unfortunately suffered from recurring respiratory complications that were attributed to her underlying neurological condition, and despite obvious predisposing factors, TEF was thought of much later. This case reinforces the need for a high index of clinical suspicion for an early diagnosis and treatment of a TEF.

A Case of Giant Coronary Artery Aneurysm with Fistulous Connection to the Pulmonary Artery: a Case Report and Review of the Literature

Giant coronary artery aneurysm is a rare condition with a reported prevalence of 0.02%. Herein, we report the case of a 79-year-old woman with a giant coronary aneurysm arising from a branch of the left anterior descending coronary artery that had a fistulous connection to the pulmonary artery. The aneurysm was removed and inflow and outflow arteries were closed surgically. Histology showed prominent mucinous degeneration and infiltration of inflammatory cells in the medial layer. After successful surgery, the patient was discharged uneventfully.

Coronary CTA assessment of coronary anomalies

Coronary anomalies occur in <1% of the general population and can range from a benign incidental finding to the cause of sudden cardiac death. The coronary anomalies are classified here according to the traditional grouping into those of origin and course, intrinsic arterial anatomy, and termination. Classic coronary anomalies of origin and course include those in which a coronary artery originates from the contralateral aortic sinus or the pulmonary artery with anomalous course. Single coronary artery anomalies, in which single coronary artery branches to supply the entire coronary tree, are also included in this category. Anomalies of intrinsic arterial anatomy are a broad class that includes myocardial bridges, coronary ectasia and aneurysms, subendocardial coursing arteries, and coronary artery duplication. Coronary anomalies of termination are those in which a coronary artery terminates in a fistulous connection to a great vessel or cardiac chamber. In the case of those anomalies associated with a risk of sudden cardiac death, the relevant imaging features on CT angiography (CTA) associated with poorer prognosis are reviewed. Recent guidelines and appropriateness criteria favor the use of coronary CTA for the evaluation of coronary anomalies. Although invasive angiography has historically been used to diagnose coronary anomalies, multidetector CT imaging techniques have now become an accurate noninvasive alternative. Cardiac CTA provides excellent spatial and temporal resolution, allowing accurate anatomical assessment of these anomalies.

Intraoperative Indocyanine Green Video-Angiography

Technical note. To describe the use of intraoperative indocyanine green (ICG) video-angiography for obliteration of a spinal dural arteriovenous fistula (DAVF) and to show a video clip. ICG video-angiography is an emerging tool for delineating intraoperative vascular anatomy, and it has a significant potential in the treatment of vascular diseases in the spine. The authors presented a case of a 73-year-old man with progressive and debilitating bilateral lower extremity weakness. The patient was diagnosed with a spinal DAVF of 10th thoracic spine based on the results of conventional spinal angiography. The patient underwent T9-10 laminotomy for microsurgical clip occlusion. Intraoperative ICG video-angiography was used before clip placement to identify the arterialized veins of the fistula and after clip placement to confirm obliteration of the fistulous connection and restoration of normal blood flow. Intraoperative ICG video-angiography serves an important role in the microsurgical treatment of DAVF. It is simple and provides real-time information about the precise location of spinal DAVF and result after obliteration of spinal DAVF.

Surgical Treatment of Circumflex Coronary Aneurysm with Fistulous Connection to Coronary Sinus Associated with Persistent Left Superior Vena Cava

Circumflex coronary arteriovenous fistula associated with aneurysmal dilatation and draining into coronary sinus (CS) is rare. A 57-year-old female presented with progressive dyspnea and was found to have a tortuous multiloculated aneurysm of the circumflex coronary artery terminating into the CS associated with a persistent left superior vena cava. The operative repair and management of coronary arteriovenous fistula are the subject of this case report and review.

Fistulous Communication of a Pancreatic Pseudocyst to the CBD - A Case Report and Review of Literature

Purpose: Background: Fistula formation is an uncommon complication of pancreatic pseudocysts. Unique and even rarer are fistulas draining into the biliary tract. We present such a case with a review of literature. Case: A 52-year old woman with non-alcoholic recurrent acute pancreatitis and previous cholecystectomy was admitted for radiating epigastric pain, nausea, vomiting, anorexia and fever. On admission, she had a lipase of 557 U/L and WBC of 11.3 K/μL. Abdominal CT showed non-necrotizing pancreatitis with a large intra-pancreatic pseudocyst. MRCP confirmed the pseudocyst measuring 17.2x4.7 cm and a dilated CBD measuring 8 mm with no choledocholithiasis. She was discharged improved after medical management. Four weeks later, she developed progressive jaundice. Outpatient workup revealed elevated total bilirubin 6.4 mg/dL, AST 88 U/L, ALT 159 U/L, and alkaline phosphatase 509 U/L. ERCP showed a severely dilated distal CBD impacted with sludge and a fistula connecting the pseudocyst to the CBD. Sphincterotomy was done to remove the purulent sludge from the CBD, after which a 10-French 7-cm straight stent was placed across the papilla to facilitate further drainage. Her jaundice and transaminase levels significantly improved post-ERCP. Two months later, repeat ERCP showed only a mildly dilated CBD with complete resolution of the fistula. Unobstructed biliary flow prompted the removal of the CBD stent. Discussion: Pancreatic pseudocysts more commonly fistulize to the stomach, duodenum, and colon but very rarely to the CBD. In our review of the literature, we found only 17 case reports describing such pathology. Majority of them involved male patients with chronic alcoholic pancreatitis. Pseudocyst drainage was accomplished through duodenal or jejunal surgical ostomy in 10 patients, while external drainage was performed in 2 patients. Endoscopically placed stents across the ampulla and connecting the pseudocyst to the CBD provided effective drainage in 3 patients. Our case is unique in that her recurrent pancreatitis was probably due to chronic cholecystitis resulting from biliary sludge or microlithiasis as confirmed by the absence of stones from her post-cholecystectomy pathology findings. Her CBD became obstructed after the fistulous connection was formed due to progressive inflammatory reaction to the pseudocyst enzyme-rich fluid. Treatment of our patient is also unique because CBD stenting was sufficient for biliary decompression and drainage of the pseudocyst contents. Repeat ERCP confirmed a resolved pseudocyst and a healed fistula.

Cerebral Arteriovenous Malformations

rteriovenous malformations (AVMs) are vascular abnormalities that onsist of multiple fistulous connections between arteries and veins ithout a normal intervening capillary bed. AVMs are thought to be ongenital. Ninety percent of all AVMs are supratentorial. The most ommon presentation of an AVM is intracerebral hemorrhage (ICH). eizure is the second most common presentation. Other symptoms nclude headache and neurological deficits related to steal phenomena or ther alteration in tissue perfusion adjacent to the AVM. To appropriately manage AVMs, it is important to understand the atural history of these vascular malformations. The decision for no reatment or for a singleor multimodality treatment paradigm also nvolves being familiar with the outcomes and risks of each treatment odality—microvascular resection, endovascular embolization, and steeotactic radiosurgery. Patient-related factors, such as age, general medcal condition, neurologic condition, occupation, and lifestyle, must also e considered. The treatment of AVMs is highly individualized. There is o universal algorithm or protocol to be followed when dealing with these nique and challenging lesions. The current treatment of AVMs includes microsurgical resection alone, reoperative endovascular embolization followed by microsurgical resecion, stereotactic radiosurgery alone, preprocedural endovascular emboization followed by radiosurgery, endovascular embolization only, and bservation only. The only way to achieve cure is with complete bliteration of the AVM. Microsurgical resection, whenever it can be one safely, is the gold standard treatment and other methods of treatment ust be measured against it. There is a well-established role for djunctive endovascular embolization of certain AVMs. Clearly, there are pecific situations, such as small deep AVMs in eloquent brain structures, here microsurgery should not be used as the primary treatment modal-

Dilated Tortuous Right Coronary Artery to Coronary Sinus Fistula

Coronary artery fistulas are rare congenital anomalies. The most common draining sites are the pulmonary artery and the right atrium, whereas drainage into the coronary sinus (CS) is reported in only few cases [1, 2]. We describe a rare combination of an enlarged and cirsoid right coronary artery (RCA) with a fistula draining into the CS. A 32-year-old man was referred for evaluation of heart murmur. He was asymptomatic and did not use any medication. The patient had a normal exercise capacity. Physical examination revealed a continuous heart murmur. The ECG showed sinus rhythm, a normal frontal axis. Chest X-ray demonstrated mild cardiomegaly. A transthoracic echocardiogram demonstrated an enlarged right atrium, right ventricle, CS, and RCA with a fistulous connection to the CS (Fig. 1a). The distal part of CS was dilated as high as 28 mm (Fig. 1b), and turbulent flow from it into the right atrium was shown (Fig. 1c). A contrast-enhanced multidetector computed tomography (MDCT) and a cardiac catheterization were performed to show vascular relationships. The MDCT demonstrated enormously dilated, tortuous RCA with a fistulous connection to the CS (Fig. 2a, b). Right heart catheterization showed normal right-sided filling pressures and a Qp:Qs of 1.7:1.0. Right coronary angiography confirmed a large and tortuous RCA and contrast medium passed from the RCA to the right atrium from the region of the CS (Fig. 3a). The left coronary artery was normal; however, the distal RCA filled retrograde via left-to-right collaterals (Fig. 3b). The patient underwent surgical closure of the fistula and did well postoperatively.

Benign post-esophagectomy gastrocardiac fistula

The development of a gastrocardiac fistula is a rare complication following retrosternal gastric conduit creation. We report a case of a 64-year-old male who presented three years after esophagectomy with massive hematemesis. A fistulous connection between his gastric conduit and right ventricle was identified and successfully treated. Although the patient had an atypical presentation and lacked most of the commonly cited risk factors, the combination of peptic ulcer disease and Candida overgrowth resulted in the formation of a gastrocardiac fistula. Adherence to treatment principles including prompt surgical intervention, adequate coverage of the repair, and antimicrobial therapy against Candida species provides the highest likelihood of success in addressing this potentially lethal disease process.

Percutaneous Closure of Congenital Coronary Artery Fistulae: Results and Angiographic Follow-Up

This study sought to assess clinical and angiographic outcomes in a series of 29 patients who underwent transcatheter closure of coronary artery fistulae (CAF). Transcatheter closure of CAF has become an alternative to surgical closure, but the reported experience is relatively limited. Medical records of all patients with CAF who underwent transcatheter closure at the Mayo Clinic, Rochester, Minnesota, between 1997 and 2010, were reviewed. Patients with other complex cardiac lesions and those requiring surgery were excluded. Twenty-nine patients with CAF underwent 36 transcatheter closure procedures. The most were women (55%), and the median age at the time of transcatheter closure was 49 years. Twenty-three patients had a single CAF. The most common presenting symptom was chest pain (52%). Thirty devices were deployed antegrade into 1 or more arterial feeders, 3 using an arteriovenous wire loop and 3 retrograde at the fistulous connection. Successful closure occurred immediately in all patients with no residual flow in 89% and with trivial flow in 11%. Four complications occurred including 2 device migrations, 1 coronary spasm, and 1 coronary thrombosis. A follow-up angiogram was obtained in 18 (62%) patients with a median time to follow-up angiography of 1.5 years. Ten patients (56%) of the 18 patients with follow-up angiography had no recanalization of embolized vessel; 4 patients (22%) had trivial recanalization, and 4 patients (22%) had large recanalization. A repeat closure procedure was performed in all 4 patients of the latter. Transcatheter closure of CAF is feasible and should be considered in carefully selected patients. Recanalization of the treated coronary fistulae can occur, so follow-up angiography or other imaging modality should be performed in these patients.

An Infant With Yellow Umbilical Drainage

Question: A 2-week-old, full-term boy was seen in the clinic with a 3-day history of yellow colored drainage coming from the umbilicus. He was initially seen by his pediatrician and subsequently referred to the tertiary hospital owing to the great concern for drainage noted from the umbilicus. He presented with no recent history of fever, rash, increased fussiness, lethargy, or signs of inflammation around the umbilicus. He was feeding well and seemed appropriate for his age. He did have other congenital anomalies, including mid cleft lip and palate and malformed ears. Physical examination revealed an alert, active, and well-developed infant. He weighed 3.54 kg (∼30th percentile), height 49.0 cm (∼20th percentile), and the head circumference was 34 cm (∼10th percentile). Vital signs were normal. He had midline cleft lip and palate, and mid face hypoplasia. The heart, chest, extremities, skin, and neurologic examination were grossly normal. The abdomen was nontender, nondistended, and without organomegaly. There was a yellow, soft substance emerging from the umbilicus with minimal erythema and tenderness at the umbilicus. A barium enema was obtained to evaluate the intra-abdominal anatomy and the discharge from the umbilicus (Figure A). The retrograde filling of the small bowel with radiopaque contrast material revealed a fistulous connection from the small bowel to the umbilicus. The contrast streamed out of the umbilicus onto the anterior abdominal wall (Figure B). What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The streaming of the contrast from the umbilicus during the barium enema confirmed a enterocutaneous fistula from the small intestines. If the omphalomesenteric (OM) duct is patent from the small bowel to the umbilicus, then fecal umbilical drainage will be noted. The OM duct or the vitelline duct is the remnant of connection between the embryonic midgut and the yolk sac. This duct provides nutrition to the developing embryo until the placenta is established.1Zafer Y. Yigit S. Turken A. et al.Patent omphalomesenteric duct.Turk J Med Sci. 2000; 30: 83-85Google Scholar By the 9th week of gestation, the duct separates from the intestines. However, if this involution fails, various residual malformations can occur. Meckel's diverticulum is the most common associated anomaly. The occurrence of patent OM ducts is rare. A contrast study is the preferred approach when an umbilico-enteric fistula is suspected. This will identify a potential intraperitoneal connection with the bowel or an extraperitoneal communication with the urinary tract.2Konvolinka C.W. Patent omphalomesenteric duct.Surgery. 2002; 131: 689-690Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Operative resection of the remnant or the umbilical anomaly is the preferred method of treatment.3Carlisle E.M. Mezhir J.J. Glynn L. The umbilical mass: a rare anomaly.Pediatr Surg Int. 2007; 23: 821-824Crossref PubMed Scopus (19) Google Scholar Segmental resection of the intestine containing the fistula or a simple excision of the diverticulum is acceptable. This patient underwent operative repair by identifying the OM remnant leading from the mid jejunum to the underside of the umbilicus. The OM fistula was resected with an end-to-end sutured anastomosis of the jejunum (Figures C and D). Interestingly, tissue pathology reports showed small segments of squamous mucosa contiguous with small bowel mucosa (Figure E) and a focal area of foveolar (gastric) mucosa (Figure F). Both Meckel's diverticulum and OM cyst may contain gastric mucosa that secretes hydrochloric acid;2Konvolinka C.W. Patent omphalomesenteric duct.Surgery. 2002; 131: 689-690Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar the presence of gastric mucosa has not been reported in OM fistulas and was identified in this case.

Congenital Arteriovenous Malformation Between the Subclavian Artery and Superior Vena Cava Presenting in Neonatal Heart Failure

Congenital arteriovenous malformations are a well-described cause of neonatal heart failure. Fistulous connections are typically intrahepatic or intracranial. We present a case of a neonate with an intrathoracic arteriovenous malformation between the subclavian artery and superior vena cava resulting in florid neonatal heart failure. This unusual fistulous connection has only rarely been reported in the literature, and in those reports, it has not resulted in neonatal heart failure.

Vein of Galen aneurysmal malformation: combined transvenous and transarterial method using a “kissing microcatheter technique”

Vein of Galen aneurysmal malformation (VGAM) is a severe pediatric neurovascular disease. Children often present with congestive heart failure in the neonatal period. In the last decades, endovascular treatment became the first therapeutic option. The purpose of this study is to report our results in the treatment of VGAM with a combined transvenous and transarterial method in the last ten years. In our cohort of 28 patients with VGAM, 22 patients were treated endovascularly between 1992 and 2010. In the last 10years, a consecutive series of 14 children were treated with a combined transvenous and transarterial method. The therapeutic goal was immediate shunt reduction of the arteriovenous malformation, especially in the neonatal period. Closure of the fistulous connections was achieved by coiling using a combined transvenous and transarterial approach, called "kissing microcatheter technique". Eight of 14 children presented in the neonatal period with severe congestive heart failure. The other six patients presented between the age of 2 and 17months. One patient died due to a non-procedural complication in another hospital 2years after the last treatment. Complete or >90% of angiographically confirmed closure of the malformation was documented in 11 of 14 patients. Normal or near-normal outcome was achieved in 9 of 13 surviving children, a non-favorable outcome was observed in four children. Control of heart failure was achieved in all patients. Endovascular treatment of VGAM using a combined transvenous and transarterial method is a safe procedure with a low complication rate. The overall outcome can be improved, especially in the high-risk neonatal group with congestive heart failure.

Transorbital Endovascular Embolization of Dural Carotid-Cavernous Fistula: Access to Cavernous Sinus through Direct Puncture: Case Examples and Technical Report

We present 2 cases of carotid-cavernous fistulas that failed multiple attempts at transarterial and transvenous embolization. Direct transorbital puncture for embolization was successful in curing the fistulas. The relevant anatomy and technique are reviewed. The first case is a 39-year-old man who presented with a 2-month history of worsening right-sided chemosis, proptosis, double vision, and progressive right eye vision loss. The second case is a 79-year-old woman with a 5-month history of right-sided chemosis and a 1-month history of complete left ophthalmoplegia. Cerebral angiography revealed an indirect carotid-cavernous fistula (CCF) in both patients, supplied by meningeal branches of the internal and/or external carotid arteries. After multiple unsuccessful attempts at transarterial and transvenous embolization, the CCFs were accessed via direct percutaneous transorbital puncture of the inferior and superior ophthalmic veins, respectively. The fistulas were then successfully occluded with a combination of Onyx and detachable coils. In rare cases in which more conventional transvenous and transarterial routes to a CCF have been exhausted, direct percutaneous transorbital puncture represents a viable means of achieving catheterization of the fistulous connection. In most cases, where a prominent arterialized superior ophthalmic vein is present, direct puncture represents a reasonable alternative to ophthalmologic cut-down procedures. Transorbital puncture of the inferior ophthalmic vein provides a direct route to the cavernous sinus in cases where the superior ophthalmic vein is atretic and inaccessible by direct surgical cut-down procedures.

An S-shaped sinoatrial nodal artery coronary artery fistula demonstrated by multidetector CT

The presented case and discussion illustrate the use of CT coronary angiography to depict coronary artery fistulae. A 41-year-old man presented with an acute myocardial infarction. Invasive angiography revealed an incidental coronary artery fistula but was unable to depict its course. CT coronary angiography was undertaken to define the course and termination of the fistula. This confirmed a fistulous connection between the left circumflex artery and the superior vena cava that followed the typical course of an S-shaped sinoatrial nodal artery. Even in such an unusual anomaly this case highlights the ability of CT coronary angiography to accurately depict the coronary artery anatomy.