# Replacement of aneurysmal right coronary artery with reconstruction of posterior descending and right ventricular branches in coronary artery fistula draining into the coronary sinus: a case report

## TL;DR

A 69-year-old woman with a large coronary artery fistula underwent successful surgery to replace the affected artery and restore normal blood flow.

## Contribution

A novel surgical technique for treating a complex coronary artery fistula with aneurysmal dilation and multiple branch reconstruction.

## Key findings

- Surgical replacement of the dilated right coronary artery eliminated shunt flow and improved coronary perfusion.
- Reconstruction of posterior descending and right ventricular branches ensured adequate blood supply to the heart.
- Postoperative angiography confirmed successful graft integration and absence of residual shunting.

## Abstract

Dilated coronary arteries associated with coronary fistulas can cause late complications, such as rupture and myocardial ischaemia due to intraluminal thrombosis and distal embolism. This case report presents the successful surgical treatment of a coronary artery fistula causing a tortuous and dilated right coronary artery (RCA).

A 69-year-old female presented with congestive heart failure and atrial fibrillation detected on the electrocardiogram. Chest roentgenography showed lung congestion and cardiomegaly, with a cardiothoracic ratio of 84%. Echocardiography revealed severe mitral and tricuspid regurgitation and pulmonary hypertension. Coronary angiography revealed a dilated RCA fistula draining into the coronary sinus, with a Qp/Qs ratio of 2.3. Surgery was performed via median sternotomy. Under cardiac arrest, mitral valve replacement and tricuspid valve plasty were performed. The RCA was divided at the proximal portion, just distal to the origin of the conus branch. Through a longitudinal incision on RCA, the orifices of the posterior descending artery and the two major right ventricular branches were identified and trimmed as buttons. The dilated RCA was replaced with the saphenous vein graft, which was sequentially anastomosed with the buttons. Postoperative angiography showed visualization of the saphenous vein and right ventricular branches, with the elimination of the huge shunt flow from the RCA.

Eliminating shunt flow, resecting the dilated portion of the RCA > 10 mm in diameter, and recreating sufficient coronary perfusion to the right ventricle by replacement of RCA are crucial for favourable early and late clinical outcomes of diffusely aneurysmal coronary artery fistula.

Graphical Abstract