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Ann Thorac Surg 2009;88:303. doi:10.1016/j.athoracsur.2008.10.004
© 2009 The Society of Thoracic Surgeons
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Images in Cardiothoracic Surgery

Left Circumflex to Bronchial Artery Fistula

Zain Khalpey, MD, Phillip Camp, Jr, MD, Michael T. Jaklitsch, MD*

Department of Thoracic Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts

* Address correspondence to Dr Jaklitsch, Department of Thoracic Surgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115 (Email: mjaklitsch{at}partners.org).

A 29-year-old man with cystic fibrosis and end-stage lung disease secondary to bronchiectasis was evaluated for an orthotopic double-lung transplant. Cardiac catheterization (Fig 1 [LCA = left circumflex artery; LAD = left anterior descending artery]) identified an unsuspected circumflex artery to bronchial artery fistula. In retrospect, the patient denied angina and had no symptoms suggestive of a steal syndrome.


Figure 1
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  		Fig 1.
 
The fistulous connection originated from the left proximal circumflex artery, passed through the pericardium (Fig 2; estimated scale 1:1), and communicated with the right bronchial artery collaterals. This fistula was due to an inflammatory phlegmon around the right hilar nodes. This unexpected finding enabled the operative team to prepare contingency plans to address this fistula during the recipient lung explant. During the operation, dilated (approximately 3 mm) collaterals of the right bronchial arteries were controlled with surgical clips. The size of the dilated plexus of bronchial artery collaterals was within previous experience with bronchiectasis.


Figure 2
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  		Fig 2.
 
A left circumflex to right bronchial artery communication was initially described by von Haller in 1803 [1]. According to Moberg [2], they can be present from birth with few hemodynamic consequences. Surgical ligation or coil embolization of the fistula has been reported [3], but is not necessary if surgery is planned.

Coronary catheterization has not been routinely performed for pretransplant cystic fibrosis patients. The new lung allocation score, however, weights catheterization data. Coronary catheterizations performed on bronchiectatic patients may reveal unsuspected arterial malformations due to the inflammatory milieu. We believe that these are easily controlled at the time of transplantation. They do not require preoperative embolization if they are asymptomatic.


   References
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 References
 

  1. von Haller A. First lines of physiology1st ed.. Troy, OH: Penniman; 1803. pp. 35.
  2. Moberg A. Anastomoses between extra-cardiac vessels and coronary arteries. I Via bronchial arteries: post-mortem angiographic studies in adults and newborn infants. Acta Radiol (Diagn) 1967;6:177-192.[Medline]
  3. Peynircioglu B, Ergun O, Hazirolan T, Cil BE, Aytemir K. Bronchial to coronary artery fistulas: an important sign of silent coronary artery disease and potential complication during bronchial artery embolization Acta Radiol 2007;48:171-172.[Medline]



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