Management of Medium to Giant Coronary Artery Fistulas (JACC Case Reports February 2026)-Article: Management of Medium to Giant Coronary Artery Fistulas

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This case series reports the management of 6 symptomatic adult patients with medium to giant coronary artery fistulas (CAFs) at a single center. CAFs are rare congenital abnormal connections between coronary arteries and cardiac chambers or vessels, often causing symptoms through shunt-related volume overload, coronary steal, arrhythmias, pulmonary hypertension, chamber enlargement, thrombosis, or ischemia.<br /><br />The authors emphasize that diagnosis and treatment planning require multimodality imaging, especially cardiac CT angiography, echocardiography, and invasive catheterization. Management was individualized based on fistula size, anatomy, shunt burden, and associated cardiac disease.<br /><br />Three patients with medium-sized fistulas were successfully treated percutaneously using coils and/or vascular plugs. These procedures led to symptom resolution and, on follow-up imaging, minimal or no residual shunting with remodeling over time. One medium-large fistula associated with pulmonary hypertension was also closed transcatheterly using an arteriovenous loop approach, which improved pulmonary vascular resistance and enabled later atrial fibrillation ablation.<br /><br />Three patients had giant fistulas, where surgery was favored or ultimately required. Reasons included very large fistula size, aneurysmal dilation, low likelihood of remodeling, thrombosis risk, concomitant coronary stenosis, and associated structural problems such as tricuspid regurgitation. Surgical strategies included fistula ligation, coronary bypass grafting, valve repair, and closure of a patent foramen ovale when needed. One giant fistula was first attempted percutaneously but later required surgery because device closure was incomplete.<br /><br />Overall, the series supports a practical approach: transcatheter closure is effective for most medium and some large CAFs, while surgery is preferred for select large and all giant fistulas, especially when other cardiac lesions or obstructive coronary disease are present.

Meta Tag

Concept Coronary Artery Fistula

Concept Fistula Size

Concept CT Coronary Imaging

Concept Cardiac Ultrasound

Concept Percutaneous Closure

Keywords

coronary artery fistula

congenital heart disease

cardiac CT angiography

multimodality imaging

transcatheter closure

coil embolization

vascular plug

surgical ligation

pulmonary hypertension

coronary steal syndrome

Coronary Artery Fistula

Fistula Size

CT Coronary Imaging

Cardiac Ultrasound

Percutaneous Closure