• Images in cardiology

Stent grafts have recently been applied for various coronary lesions such as coronary perforation, coronary aneurysm, and fistula. We report a case of coronary arteriovenous fistula associated with atherosclerotic plaque successfully treated with combined membrane covered and uncovered stent implantation in a patient who presented with acute myocardial infarction. He was found to have acute ST segment elevation myocardial infarction. A 12 lead ECG showed ST segment elevation of 3 mm over the precordial leads (V1–V5). Cardiac enzymes were elevated and peaked at 1161 iu/l of creatine kinase (CK), 130 iu/l of CK-MB, 0.804 ng/ml of troponin T, and 7.98 ng/ml of troponin I. Two dimensional echocardiogram demonstrated severe hypokinesia in anteroseptal and anterior wall. A coronary angiogram revealed critical stenosis in the proximal left anterior descending coronary artery and prestenotic dilatation with a large fistula drained into the main pulmonary artery (panel A). After predilation in fistula and stenosis sites, a polytetrafluoroethylene (PTFE) covered stent (3.0 × 16 mm, JOSTENT GraftMaster, Jomed, Germany) was deployed. After graft stenting, an additional uncovered stent (3.0 × 18 mm, Arthos inert, AMG, Korea) was implanted just below the graft stented site. After stenting, no visible large fistula and stenosis were found on angiography (panel B).