PMC5987320_01
(a) 320-row coronary CTA. The single coronary artery view shows the anterior course of the separate right coronary artery coming off the LAD. This is the anterior view. (b) Selective coronary angiography of the LMT shows the LAD and the LCX with weak contrast effects and a CAF with "multiple caliber change" of the RCA to the right ventricle (arrowhead). (c) Occlusion test on the proximal site of CAF using an occlusion balloon (arrowhead). (d) Engaged microcatheter in the distal RCA and embolization using a detachable coil. (e) One year after coil embolization, selective LMT coronary angiography clearly distinguishes the contrast effect of the LAD and LCX, the sinus node branch branching from LCX (white arrow), and right ventricular branches from the proximal side of the RCA (asterisks). The proximal end of the coil-embolized CAF formed a thrombus and occluded (arrowhead). CAF: coronary artery fistula; CTA: computed tomography angiography; LAD: left anterior descending coronary artery; LCX: left circumflex coronary artery; LMT: left main coronary trunk artery; RCA: right coronary artery.
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fig1
Coronary computed tomography angiography (CTA) with three-dimensional volume rendering revealed the thick and torsional RCA originating from the left anterior descending coronary artery (LAD), with fistulous communication to the right ventricle via a large vessel (Figure 1(a)). CAF was a "beaded and caliber change" form. Coronary angiography could not distinguish the RCA's peripheral branches (Figure 1(b)). Using the PercuSurge GuardWire  system (Medtronic, Santa Rosa, CA, USA), an occlusion test was performed in the proximal site of the RCA using a 6 mm balloon (Figure 1(c)). Coil embolization was performed with GDC  Detachable Coils (Boston Scientific, Fremont, CA, USA) (Figure 1(d)). The collateral vessels from the developed septal branch, LAD, and sinus node branch supplemented the peripheral areas of the RCA (Figure 1(e)).