Iatrogenic aortocoronary vein fistula : a case presentation and review of the literature
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A patient underwent aortocoronary saphenous bypass grafting to the left anterior descending coronary artery (LADA) and its first diagonal branch for the relief of severe angina pectoris. There was difficulty in exposure of the LADA, which was covered by a thick layer of epicardial adipose tissue. Post-operatively the patient continued to experience severe retrosternal pain which prompted early repeat coronary angiography. This revealed an aortocoronary vein fistula (AVF) secondary to the inadvertent anastomosis of one of the saphenous vein grafts to the left anterior descending coronary vein (LADV). It was only after this procedure that clinical examination revealed a grade 2/6 high-frequency continuous murmur best heard in the 2nd and 3rd left intercostal spaces. The persistance of severe angina pectoris at rest and on effort led to performance of revision operation. The LADV was then transected and ligated, and an extended saphenous vein reimplanted into the LADA proper. This provided complete relief from angina. This is the first such case reported in South Africa and the sixth documented. In all the aortosaphenous vein grafts had been inserted into the LADV; all exhibited the classic continuous murmur postoperatively, apart from 1 patient who had an ejection systolic murmur. None of the other 5 patients complained of postoperative angina and only 3 were subjected to revision surgery. The literature is reviewed, with emphasis on the rationale for performing the first elective aortocoronary vein anastomosis in 1968. Clinical features of iatrogenic AVF are detailed and an attempt is made to assess when re-operation is indicated. It is easy to fail to notice this complication; however, its correction can have a dramatic effect on the patient's symptoms. It is the author's belief that many more such cases exist but are not being detected, probably because of lack of appreciation of the possibility of this iatrogenic condition occurring.