Case Report
A 48-year-old woman was referred to our institution for surgical
management of ruptured CAA associated with CAVFs. Four days before
referral, she had experienced chest discomfort followed by presyncope.
Following medical examination at the neighboring hospital, her condition
was diagnosed as cardiac tamponade due to rupture of the CAA with CAVFs.
Computed tomography (CT) scan revealed an aneurysmal formation measuring
3.0 × 2.0 cm, which was located at the left anterior aspect of the
pulmonary artery trunk with a large amount of pericardial effusion (Fig.
1a). Pericardial drainage was performed and 100 mL of blood was
aspirated (Fig. 1b). Subsequently, her symptom improved immediately.
Additionally, CT scan revealed that the aneurysm was communicated with
the left and right coronary arteries (RCA) through anomalous fistulous
vessels that drained into the pulmonary artery trunk (Fig. 1c).
Fistulous vessels originating from proximal RCA and left anterior
descending artery (LAD) were confirmed by coronary angiography. With the
diagnosis of ruptured CAA with CAVFs, operation was urgently performed.
The patient underwent a median sternotomy. Surgical exposure revealed
mild fibrous adhesion mainly around the pulmonary artery and a
saccular-type mass measuring 3.0 cm in diameter at the left anterior
surface of the pulmonary artery (Fig. 2a). Prior to repair of the CAVFs,
intraoperative near-infrared fluorescence imaging of CAVFs was performed
using photodynamic eye (Hamamatsu Photonics, Hamamatsu,
Japan).7 Approximately 15 seconds after intravenous
injection of indocyanine green, abnormal fistulous vessels were
visualized at the anterior surface of the pulmonary artery (Fig. 3a,
3b). Cardiopulmonary bypass was established between the ascending aorta
and bicaval cannulation. Following aortic cross clamping, cardiac arrest
was achieved by antegrade cardioplegia. First, the feeding arteries
originating from the proximal RCA were ligated at their origin. Second,
the pulmonary artery was incised longitudinally and the fistulous
opening that communicated between the pulmonary artery and aneurysm was
closed with a pledgeted suture (Fig. 2b). The CAA was opened and the
drainage sites from the feeding arteries were identified by antegrade
infusion of cardioplegia (Fig. 2c). These drainage sites were closed
from within the aneurysm followed by aneurysmorrhaphy. Weaning from the
cardiopulmonary bypass was uneventful. After completion of surgical
repair, no residual CAVFs was confirmed from repeated fluorescence
imaging (Fig. 3c). The patient’s postoperative recovery was uneventful
and she was discharged 7 days after surgery. Postoperative CT did not
reveal any evidence of residual fistulas. Recurrent CAVFs and CAA were
not observed during follow-up. Written informed consent was obtained
from the patient for the publication of this report.