PMC8083030_01
A-C. Transthoracic echocardiography shows the arteriovenous fistula (AVF, arrow) between the right subclavian artery (RSA) and the superior vena cava (SVC); D. Color Doppler guided continuous-wave Doppler interrogation of the fistula shows high velocity flow signals moving from the RSA into the SVC throughout the cardiac cycle; E, F. Computed tomographic angiography and three-dimensional reconstruction shows AVF (arrow); G. Arterial angiography indicates contrast material leaking into the SVC through the AVF (arrow); H. The fistula is successfully closed using a 10/12 mm Amplatzer Ductal Occluder (asterisk); I. Transthoracic echocardiography shows no residual shunt; RA : right atrium; RV : right ventricle.
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However, imaging in unconventional right parasternal windows, which was close to the site of the murmur, revealed a dilated right subclavian artery (RSA) with a 7-mm fistula to the superior vena cava (SVC) (Fig. 1A-C; Suppl. SVC throughout the cardiac cycle, consistent with the fistula (Fig. 1D). Subsequent computed tomographic angiography confirmed a congenital arteriovenous fistula (AVF) between the RSA and the SVC (Fig. 1E, F). The arterial angiography showed contrast material leaking from the RSA into the SVC (Fig. 1G). The fistula was successfully closed using a 10/12 mm Amplatzer Ductal Occluder (Fig. 1H). TTE revealed no residual shunt (Fig. 1I). The patient dramatically improved clinical symptoms and made an uneventful recovery after occlusion.