Download Iatrogenic Fistula from the Aorta to the Left Marginal Coronary Vein*

tilage defects have been described with any frequency. Bronchial atresia is relatively rare as a cause of CLE,but the late
asymptomatic presentation with typical radiographic features of a coin lesion makes this diagnosis more likely. The
additional finding of a bronchogenic cyst is an experiment of
nature which, assuming both anomalies develop at the same
time, allows us to time the appearance of the atretic segment
more accurately than has been possible before.
1 Warner JO, Rubin S, Heard BE. Congenital lobar emphysema: a
case with bronchial atresia and abnormal bronchial cartilages. Br
J Dis Chest 1982;76:177-&
2 Hislop A. Reid L. Growth and development of the respiratory
system-anatomicaldevelopment. In: Davis JA, Dobbing J (eds).
Scientific foundations of pediatrics. London: Heinemann
3 Schuster SR. Hanis GBC. Williams AJ, Kirkpatrick J, Reid L.
Bronchial atresia: a recognizable entity in the pediatric age
group. J Ped Surg 1978;13:682-89
4 Reid L. The pathology of emphysema. London: Lloyd-Luke,
1967
5 O'Rahilly R, Boyden EA. The timing and sequence of events in
the development of the human respiratory system during the
embryonic period proper. Z Anat Entwicklungsgesh 1973;141:
237-50
6 Erakus AJ, Griscom NT, McGovern JB. Bronchogenic cysts of
the mediastinum in infancy. N Engl J Med 1964;281:1150-53
7 Binet JP, Nezelof C, Fredet J. Five cases of lobar tension
emphysema in infancy: importance of bronchial malformation
and value of post-operative stemid therapy. Dis Chest 1962;
41:126-32
8 Campbell PE. Congenital lobar emphysema; etiological studies.
Aust Pediatr J 1960;5:226-31
9 Shafir R, J d e R. Kalter Y. Bronchiectasis: a muse of infantile
lobar emphysema. J Pediat Surg 1976;11:107-12
10 Hislop A, Reid L. New pathological findings in emphysema of
childhood. 1. Polyalveolar lobe with emphysema. Thorax 1970;
25682-85
Iatrogenic Fistula from the Aorta to
the Left Marginal Coronary Vein*
Z? john Ross, M.D.; and C w n C . jang, M.D.
We report t h e first documented case of iatrogenic aortocoronary fistula to the left marginal coronary vein following
coronary bypass surgery. Unique clinical data, findings
from catheterization, a n d angiographic features a r e presented and compared with those in the seven previously
reported cases of iatrogenic aortocoronary venous fistulae
atter coronary bypass operations.
A
rare but recognized complication of surgery for coronary
revascularization is an aortocoronary venous fistula
caused by the inadvertent distal anastomosis of a saphenous
vein bypass graft to a coronary vein instead of to a coronary
artery. The present patient had undergone an intended bypass operation to the left circumflex or intermediate artery
*From the Cardiovascular Laboratories, Loma Linda University
Medical Center, Loma Linda, CA.
Reprint requests: Dr long. Cardiovascular Laboratories, Room
2434, Lomo Lindo Uniwrsity Medical Center, Loma Linda, California 92354
FIGURE
1. Frame from 35-mm cineangiogram on i O O left anterior
oblique projection showing "numeral-3" appearance of opacification
of aortocoronary saphenous vein graft (SVG) anastomosed to proximal left marginal coronary vein (LMY)near its junction with great
cardiac vein (GCV)and so con~municatingvia coronary sinus (CS) to
right atrium (RA). A, distal anastomosis of saphenous vein graft.
and is the first described with an iatrogenic aortocoronarv
venous fistula to the left marginal coronary vein. Observed
features of this case are the absence of a continuous murmur
and the presence of a small shunt by oximetric studies.
A @-year-oldman with recurrent pain in the chest had a history of
and triplemyocardial infarction. a Vineberg prvcedure in lW,
vessel coronary bypass surgery at another hospital in hlay 1982.0 1 1
physical examination, there was a short, soft systolic mllrmur at the
upper left sternal border, but no continuous nlurrnilrs were detected.
The electrocardiogram showed an "old" inferior mycwardial infarction. A chest roentgenogram showed persistent postoperative elevation of the left hemidiaphragm. The left ventriculogram was nor~nal.
The ejection fraction was 50 percent, and the left cardiac pressures
were normal.
The coronary arteriogram demonstrated a proximal c~vlusionof
the dominant right cwronary artery, of which the posterior descending and posterolateral branches were supplied by a patent jurnp vein
graft. There was a severe proximal stenosis of the anterior descending cwronary artery. with gvod distal How via a second patent bypass
graft. A moderately large unbypassed intermediate coronary artery
had a significant proximal stenosis. The small left circumflex curonary artery had a severe stenosis at its origin. Contrast ~nediurn
injected down a third bypass graft entered the left marginal vein
close to its junction with the great cardiac vein and drained directly
into the right atrium (Fig 1).
Right cardiac catheterization and oximetric studies (two runs)
showed normal pressures and a small but definite left-to-rightshunt
at low right atrial level. The QP:QS shunt ratio was 1.4:l.O.
Five published cases of aortocoronary venous fistulae were
reviewed in 1982 by Przybojewski,'who added another. Subsequently, one more case has appeared,' making a total of
seven. All were men aged 43 to 66 years, with angina (except
one who had intractable ventricular tachycardia). Angina was
relieved after surgery in four of six patients. The sites of graft
insertion numbered one (one patient), two (hvo patients),
three (three patients), and four (one patient). A continuous
Iatrogenic Fistula from Aorta (Ross. Jeng)
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murmur in the second or third left intercostal mace was
heard in six of the seven patients. In five cases with murmurs,
oximetric data were normal, but in one of these, a left-toright shunt was confirmed by a hydrogen detection electrode.
The aortocoronary venous fistula involved the left anterior
descending coronary vein in all six patients undergoing surgery for angina and involved the posterior interventricular
coronary vein in the patient with intractable ventricular arrhythmia. Vieweg3 makes brief anecdotal mention of three
further incidents, all involving the left anterior descending
coronary vein.
Our report is the first to describe an iatrogenic aortocoronary venous fistula to the left marginal coronary vein. It is
likely that the intermediate or circumflex coronary artery
was the intended target vessel. The angiogram of the fistula
in the 70" left anterior oblique projection (Fig 1) resembles
the arabic numeral, "3."This appearance (like that illustrated
in the case reported by Vieweg3), together with rapid transit
of contrast material through the coronary sinus to the right
atrium, would appear to be characteristic ofan aortocoronary
venous graft fistula.
The absence of a continuous murmur in our patient might
be explained by obesity and the deeper posterior anatomic
site of the fistula. The soft systolic murmur in the present
case probably originates from the patent aortocoronary bypass graft to the anterior descending coronary artery.'
Our patient is unique in that a left-to-right shunt was
detectable by oximetric studies. Though unexpected and of
small magnitude, this shunt was apparent on two sample
runs. Nevertheless, sampling error cannot be absolutely excluded; however, the majority of congenital coronary arteriovenous fistulae which drain into the right ventricle, right
atrium, or coronary sinus do exhibit small shunt^.^ Furthermore, the magnitude of the shunt detected in the present
case may be augmented not only by the relatively large caliber of the venous bypass graft, but also by the fact that the
site of oximetric sampling could have been very close to the
coronary sinus. The lack ofmurmur may also be explained by
the relatively large aortocoronary venous shunt.
In conclusion, we present the clinical features, data from
catheterization, and angiographic findings in the first reported case of iatrogenic aortocoronary venous fistula to the
left marginal coronary vein. The absence of a continuous
murmur, the presence of a detectable shunt by oximetric
studies, and the arabic-numeral-"3" angiographic shape of
the aortocoronary venous fistula are observed features of the
case.
1 Przybojewski JZ. Iatrogenic aortocoronary vein fistula: a case presentation and review of the literature. S Afr Med J 1982;62908-17
2 Hubert JW, Thanavaro S, R u b R, Connors J, Oliver GC. Saphenous vein bypass to the posterior interventricularvein: an unusual
complication of coronary artery surgery. South Med J 1982; 75:
1144-46
3 Vieweg WVR. Continuous murmur following bypass surgery.
Chest 1981; 79:4-5
4 Karpman L. The murmur of aortocoronary bypass. Am Heart J
1972; 83:179-81
5 Friedman WE Congenital heart disease in infancy and childhood.
In: Braunwald E, ed. Heart disease: a textbook of cardiovascular
medicine. Philadelphia: WB Saunders Co, 1980
graphic Abnormalities of Right Atrial
Metastatic Tumors in Hepatoma*
B. L. Chia, M.B.,B.S.,EC.C.P;
MauriceH. Choo, M.B.,B.S.,EC.C.P;LennyTan,
M.B.,B.S.;
ArthurTan, M.B.,B.S.;C.]. Oon, M.D.;and
E H. Chew, M.B.,B.S.
We describe two patients suffering from hepatoma who presented with right atrial metastatic tumors as a result of
invasion of the inferior vena cava and extension into the
right atrium. Two-dimensional echocardiographic studies
detected the right atrial tumor during life in both patients
and the invasion of the inferior vena cava in one patient.
M
etastatic tumors in the right atrium as a result of direct
invasion and extension up the inferior vena cava in
patients suffering from hepatoma are extremely uncommon.'
A 42-year-old Oriental man presented with dyspnea and abdominal swelling of two months' duration. Clinical examination revealed
elevation of the jugular venous pulse up to the angle of the jaw.
Auscultation of the heart revealed no abnormalities, and the blood
pressure was 130185 mm Hg. Moderate ascites and mild jaundice
were observed. The liver was enlarged 4 cm below the right costal
margin and was hard in consistency.
A chest x-ray film showed a slightly enlarged heart, and the
electrocardiogram was normal. The findings from serum biochemical tests were all normal, except for a total serum bilirubin
level of 3.5 mg/100 ml. During right heart catheterization the
catheter could not be manipulated beyond the lower part of the
inferior vena cava. Angiographic studies in this position showed total
obstruction of the inferior vena cava, resulting in multiple collateral
channels. Angiography with contrast dye injected at the superior
vena caval-rightatrial junction showed a large mobile filling defect in
the right atrium (labelled T)consistent with a tumor moving fonvard
and backward across the tricuspid valve during diastole and systole
(Fig IA). Selective celiac arterial angiography showed multiple
vascular lesions throughout the whole liver which were typical of a
hepatoma.
The patient was treated medically and died two months later.
Percutaneous liver biopsy, which was obtained just after death,
showed hepatoma on microscopic examination. Consent for
necropsy was not obtained.
A 58-year-old Oriental man presented with abdominal swelling.
Clinical examination revealed a markedly elevated jugular venous
pulse. Auscultation of the heart was normal, and the blood pressure
was 140185 m m Hg. The liver, which was enlarged 5 cm below the
right costal margin, was nodular and hard.
An ECG and chest x-ray film were both normal. Results of serum
biochemical and hepatic function tests were all normal. The serum
a-feto-protein level was grossly elevated at 650pglml. Percutaneous
liver biopsy revealed hepatoma on microscopic examination. Inferior
*From the Department of Medicine, National University of
Singapore, Singapore (Drs. Chia, Choo, A. Tan, and Oon); the
Department of Diagnostic Radiology, Singapore General Hospital,
Singapore (Dr. L. Tan); and Lau King Howe Hospital, Sibu,
Sarawak (Dr. Chew).
Reprint requests: DI:Chia, University Department of Medicine,
Singapore General Hospital, Singapore 0316
CHEST 1 87 1 3 / MARCH. 1985
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