case_images: PMC4007787_01
case_images: Transthoracic echocardiography. Abnormal, tortuous vessels were observed around the right coronary artery, and flow signals were detected by Doppler color flow imaging (a), (b). Abnormal vessels, predominantly exhibiting diastolic flow signals, were observed around the pulmonary trunk (c), (d).
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case_images: fig1
case_images: However, we evaluated the parasternal long-axis view at the aortic valve level and observed abnormal, tortuous vessels around the right coronary artery (RCA) (Figures 1(a) and 1(b)). Doppler color flow imaging revealed predominantly diastolic flow signals (Figure 1(d)), close to the pulmonary trunk (Figure 1(c)).
case_images: Coronary angiography. Fistula vessels (arrows) with a saccular aneurysm were observed originating from the proximal right coronary artery and joined the pulmonary artery (PA) (a). Fistula vessels (arrows) originating from the proximal left anterior descending artery joined the PA (b).
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case_images: fig2
case_images: CAG (Figures 2(a) and 2(b)) and coronary computed tomography (CT) (Figures 3(a) and 3(b)) performed for further investigation revealed dilated fistula vessels originating from the proximal RCA and left anterior descending artery (LAD) and joining the pulmonary trunk; moreover, we detected a saccular aneurysm 1 cm in diameter, around the RCA.
case_images: Coronary computed tomography. An axial section of the computed tomography (CT) image revealed dilated vessels around the pulmonary artery PA (a). Three-dimensional CT revealed a saccular aneurysm (arrow), 1 cm in diameter, around the right coronary artery (RCA), and fistula vessels originating from the proximal RCA and left anterior descending artery joined the pulmonary trunk (b).
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case_images: fig3
case_images: CAG (Figures 2(a) and 2(b)) and coronary computed tomography (CT) (Figures 3(a) and 3(b)) performed for further investigation revealed dilated fistula vessels originating from the proximal RCA and left anterior descending artery (LAD) and joining the pulmonary trunk; moreover, we detected a saccular aneurysm 1 cm in diameter, around the RCA.
case_images: Operative findings. A coronary artery aneurysm was detected around the right coronary artery (RCA) and fistula vessels originating from the proximal RCA and left anterior descending artery (LAD) into the pulmonary trunk (a). The aneurysm was ligated and resected, and the fistula vessels were clipped (b), (c). Fistula vessels from the LAD were ligated (d), and fistula vessels around the pulmonary trunk were ligated and clipped (e).
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case_images: fig4
case_images: Surgical findings (Figure 4(a)) concurred with the CAG and coronary CT findings. Fistula vessels between the proximal RCA and pulmonary trunk were ligated and clipped (Figures 4(b) and 4(c)); a saccular aneurysm, 1 cm in diameter around the proximal RCA, was resected. Fistula vessels between the proximal LAD and pulmonary artery (PA) were ligated and clipped (Figures 4(d) and 4(e)).
case_images: Pathological findings. The resected aneurysm revealed hypertrophic walls comprising proliferating fibroblasts covered with thin elastic fibers (a), (b). Few atherosclerotic changes were evident in the aneurysm walls. (a) Elastica van Gieson stain; (b) hematoxylin and eosin stain.
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case_images: fig5
case_images: Very few atherosclerotic changes were evident in the aneurysm walls (Figures 5(a) and 5(b)).