Unusual cause of angina in postpercutaneous transluminal coronary angioplasty patient

Shankar Paul Chowdhury; Biswajit Majumder; Shilanjan Roy; Sandip Ghosh

doi:10.4103/0189-7969.201912

CASE REPORT

Year : 2017 | Volume : 14 | Issue : 1 | Page : 51-53

Unusual cause of angina in postpercutaneous transluminal coronary angioplasty patient

Shankar Paul Chowdhury, Biswajit Majumder, Shilanjan Roy, Sandip Ghosh
Department of Cardiology, R. G. Kar Medical College, Kolkata, West Bengal, India

Date of Web Publication

10-Mar-2017

Correspondence Address:
Shilanjan Roy
Department of Cardiology, R. G. Kar Medical College, 1, Khudiram Bose Sarani, Kolkata - 700 004, West Bengal
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0189-7969.201912

Abstract

Among the many causes of Post Percutaneous transluminal coronary angioplasty angina (Post PTCA angina), stent restenosis is the most important cause. Other causes include incomplete revascularization, microvascular angina, and appearance of new lesions. Coronary arterio-venous (A-V) fistula is a rare cause of angina following PTCA. We hereby report a case of post-PTCA angina caused by coronary A-V fistula.

Keywords: Angina, angioplasty, coronary arterio-venous fistula, unusual cause

How to cite this article:
Chowdhury SP, Majumder B, Roy S, Ghosh S. Unusual cause of angina in postpercutaneous transluminal coronary angioplasty patient. Nig J Cardiol 2017;14:51-3

How to cite this URL:
Chowdhury SP, Majumder B, Roy S, Ghosh S. Unusual cause of angina in postpercutaneous transluminal coronary angioplasty patient. Nig J Cardiol [serial online] 2017 [cited 2023 May 29];14:51-3. Available from: https://www.nigjcardiol.org/text.asp?2017/14/1/51/201912

Introduction

Angina following a percutaneous transluminal coronary angioplasty (PTCA) can be due to many reasons. Among them, stent restenosis is the most common cause. Other less common causes include incomplete revascularization and appearance of new lesion. Preexisting untreated coronary arterio-venous (A-V) fistula is a very rare cause of angina in a post-PTCA patient. Here, we report a case of post-PTCA angina due to preexisting coronary A-V fistula.

Case Report

A 42-year-old male was admitted to our department with history of exertional chest discomfort since last 2 months. He was a known case of diabetes with coronary artery disease (CAD) with history of PTCA and stenting to left anterior descending (LAD) artery 3 months back. He was nonhypertensive and nonsmoker.

Three months back, he was admitted and evaluated for his symptoms of chronic stable angina (class II, duration-1 year) in a hospital on Southern India. Electrocardiogram (ECG) was normal, and echocardiography showed no regional wall motion abnormality (RWMA) at rest with left ventricular ejection fraction (LVEF) of 60% during that time. Treadmill test (TMT) was positive for provocable ischemia. Blood and biochemical investigations were within normal limits. Coronary angiography (CAG) was performed which showed significant narrowing of mid-LAD and normal right coronary artery (RCA) and left circumflex artery. He was taken up for elective PTCA. PTCA with stenting to LAD was done with a sirolimus-eluting stent (2.75 mm × 24 mm) to mid-LAD. Procedure was uneventful, and he was discharged from hospital after 2 days with aspirin, clopidogrel, metoprolol, ramipril, and statin.

Post-PTCA, patient's symptoms improved markedly, but some degree of exertional chest pain persisted even on optimum medical therapy. Two months after, the procedure repeat TMT was performed which was positive for provocable ischemia. He attended cardiology outpatient department of our hospital and was admitted for further evaluation. On admission, his resting ECG showed normal sinus rhythm 80 beats/min. Routine hematological and biochemical investigations were within normal limits (creatinine 1.2 mg%, hemoglobin 10.6 g%). Initial echocardiogram showed no RWMA with LVEF 65%. The patient was taken for CAG keeping in mind the possibility of stent restenosis contributing to his anginal symptoms.

CAG was done in our hospital which showed patent LAD stent with 20%–30% prestent, peri-stent, and poststent narrowing; distal thrombolysis in myocardial infarction 3 flow was present [Figure 1]. Left main coronary artery was small and disease free; RCA showed minor disease. However, interestingly, an A-V fistula originating from distal RCA (posterolateral branch) and draining to right ventricle (RV) chamber was seen in angiography [Figure 2].

Figure 1: (a) Coronary angiography of left system (cranial view) showing patent left anterior descending stent with thrombolysis in myocardial infarction 3 flow. (b) Coronary angiography of left system (right anterior oblique caudal view) showing minor in-stent and peri-stent restenosis

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Figure 2: (a) Coronary angiography of right system (view) showing two arterio-venous fistulae originating from the right coronary artery and draining to cavity (white arrows). (b) Coronary angiography of right system (cranial view) showing two arterio-venous fistulae originating from the right coronary artery and draining to right ventricle cavity

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Discussion

Coronary artery fistula (CAF) is defined as an anomalous communication between a coronary artery and a major vessel or a cardiac chamber. It is an uncommon form of congenital heart disease that occasionally causes symptoms by shunting blood flow away from the myocardial capillary network.

They represent the most common hemodynamically significant congenital coronary abnormality.^[1] The etiology of CAFs may be congenital, traumatic, or iatrogenic, i.e., it may develop after coronary intervention or valve replacement.

Most of these patients are asymptomatic, but angina episodes, heart failure, myocardial infarction, coronary steal, and endocarditis have been reported in few cases.^[2] Fistulas more frequently involve the RCA (55%–60%) and usually drain into right heart chambers.^[3]

In our patient, symptoms were attributed to coronary steal phenomenon due to the presence of large CAF communicating RCA and RV and not due to any critical in-stent restenosis or epicardial coronary artery lesion. It was concluded that initially, the patient had symptoms of angina both due to critical LAD stenosis and coronary steal phenomenon due to the presence of coronary A-V fistula.

Post-PTCA patient's symptoms partially improved due to LAD revascularization, but some amount of symptoms persisted due to the presence of coronary steal. On review of the first CAG, it was seen that A-V fistula was present even in the first angiographic study, but probably, it was not given much importance, and significant LAD narrowing was thought to be the culprit lesion responsible for patients recurrent anginal pain.

Surgical closure of the fistula is safe and effective.^[4],[5] Recent advances in interventional techniques now allow closure of CAF with the use of detachable coils and balloons; this has become the initial treatment of choice as it allows for less duration of hospital stay and earlier ambulation.^[6],[7]

The patient was offered options for surgical closure or coil embolization of the coronary A-V fistula, but the patient refused any further intervention. He was put on metoprolol 100 mg/day with which his symptoms subsided to some extent, and he was discharged.

Conclusion

In cases where A-V fistula is present along with any significant obstructive CAD, it is difficult to measure how much symptoms are being produced by the coronary artery lesion and how much due to A-V fistula causing coronary steal phenomenon. Contribution of A-V fistula in producing anginal symptoms can only be unmasked after revascularization of target lesion.

Hence, any A-V fistula when found along with obstructive CAD during CAG while evaluating a patient with anginal symptoms should be given due importance as it can be responsible for the symptoms by causing coronary steal phenomenon which might require necessary intervention for symptom relief.

Although A-V fistula can cause anginal symptoms, our case is unique in the sense that very few cases of A-V fistula as a cause of post-PTCA angina have been reported.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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