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(Circulation. 2003;107:1447.)
© 2003 American Heart Association, Inc.

Images in Cardiovascular Medicine

Late Internal Mammary Arteriovenous Fistula

Krishna Kathir, MBBS; Richmond W. Jeremy, MBBS, PhD

From the Department of Cardiology, Royal Prince Alfred Hospital (K.K.), and the Department of Medicine, University of Sydney (R.W.J.), Sydney, New South Wales, Australia.

Correspondence to Krishna Kathir, Department of Cardiology, Royal Prince Alfred Hospital, Missenden Road, Camperdown 2050, New South Wales, Australia. E-mail krishnakathir{at}bigpond.com

A 51-year-old asymptomatic woman was found to have a continuous murmur at the left lower sternal edge and in the interscapular area. Eight years earlier, she had a Bentall’s operation for an aortic root aneurysm secondary to Marfan’s syndrome. The prosthetic aortic valve sounds were normal, with an ejection murmur across the valve. A transesophageal echocardiogram showed no intracardiac shunt and normal function of the aortic valve prosthesis. Subsequent cardiac catheterization and angiography showed a large left internal mammary artery with a fistulous connection into the adjacent internal mammary veins at the level of the diaphragm (Figure 1). The fistula was occluded with coil embolization (Figure 2), and the continuous murmur disappeared. The distal location of this fistula suggests that it may have resulted from damage caused by insertion of a chest drain at the time of aortic surgery.

View larger version (166K): [in this window] [in a new window]   Figure 1. Selective left internal mammary artery angiogram showing a dilated internal mammary artery flanked by paired dilated internal mammary veins (arrows) communicating distally via a saccular fistula.

View larger version (160K): [in this window] [in a new window]   Figure 2. Post-embolization angiogram showing closure of the fistula with only the left internal mammary artery visible. The embolization coils can be seen in the distal section of the artery.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kathir, K. Articles by Jeremy, R. W. Search for Related Content PubMed PubMed Citation Articles by Kathir, K. Articles by Jeremy, R. W.