Aneurysmal Coronary Artery Fistulae: How Big is Big Enough?

Coronary artery fistula (CAF) is the most common congenital anomaly of coronary arteries. Management strategies for CAF causing symptoms and large shunting are well described. With growing use of noninvasive imaging modalities, the diagnosis of asymptomatic CAF has increased. This poses challenge on the management of CAF with high-risk features as therapeutic strategy of incidentally found CAF remains open to debate. The actual risk of complications in such cases is mere speculations based on small studies and need to be revisited. We describe the case of an asymptomatic 78-year-old woman with a large saccular coronary aneurysm associated with coronary artery to pulmonary artery fistula that was treated successfully using coils. We discuss the updated literature on the management of CAF as well.