CTICasesCongenital Right Coronary Artery Aneurysm with Fistulization to the Coronary Sinus
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Imaging findings
Chest radiography demonstrates an enlarged cardiomediastinal silhouette, characterized by a large abnormal mediastinal mass predominantly on the right, accompanied by a narrow vascular pedicle and a pericardial drain. Cardiac MR shows a persistent left-sided superior vena cava (SVC) draining into the coronary sinus. To the right of the aorta, there is a giant, heterogeneous structure communicating directly with the origin of the right coronary artery, which transitions into a large, serpiginous vessel that connects to the coronary sinus. A complex pericardial effusion, pleural effusions, and a thrombus within the aneurysmal sac are also present.
Key takeaways
A congenital coronary artery fistula can lead to massive aneurysmal dilation of the involved coronary artery over time due to high-flow, low-pressure hemodynamics, particularly when draining into the coronary sinus or right atrium. Despite a high pulmonary-to-systemic flow ratio (Qp:Qs of 4:1 in this case), patients can remain remarkably asymptomatic or present only with mild dyspnea and tachycardia. Surgical intervention typically involves excluding the aneurysm and fistulous tract, followed by coronary artery reimplantation.
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