A Rare Triple Coronary and Pulmonary Artery Fistula Involving the RCA and LAD: Successful Coil Embolization with Long Term Resolution

Abstract

Background and purpose: Coronary artery fistulas are uncommon congenital anomalies, found in approximately 0.9% of the population. While many remain clinically silent, complex fistulas may produce ischemia, heart failure, or arrhythmic complications. We present a rare case of a right coronary artery (RCA)–pulmonary artery (PA) fistula with an additional branch to the left anterior descending artery (LAD), successfully managed with transcatheter coil embolization and documented long-term resolution.

 Methods: A 24-year-old male with an eight-year history of exertional dyspnea, chest pain, and palpitations was evaluated. Electrocardiography showed normal sinus rhythm, and echocardiography revealed preserved left ventricular ejection fraction (60%). Coronary computed tomography angiography demonstrated abnormal communication between the RCA, PA, and LAD systems.

 Results: Coronary angiography confirmed a large RCA-originating fistula crossing anterosuperior to the right ventricular outflow tract and draining into the main PA trunk, with a secondary branch to the LAD causing ischemia via coronary steal. Using an Amplatz Left 1 guiding catheter and BMW wire, three detachable coils were deployed, achieving complete occlusion. The patient was discharged on dual antiplatelet therapy and remained asymptomatic at one- and six-month follow-ups, with CT angiography confirming durable closure and no residual shunt.

 Conclusion: Triple-communication coronary-pulmonary fistulas involving both RCA and LAD are exceptionally rare, with only isolated cases reported. This case highlights the feasibility and long-term efficacy of coil embolization in managing anatomically complex coronary-pulmonary connections and underscores the importance of individualized catheter strategies for optimal outcomes.