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BMJ Case Rep. 2015; 2015: bcr2014208880.
Published online 2015 March 27. doi:  10.1136/bcr-2014-208880
PMCID: PMC4386475

A significant ‘coronary steal’ by thebesian veins, a rare congenital coronary defect masquerading as acute coronary syndrome

Description

A 72-years-old woman presented with intermittent chest pains, anterolateral T-wave inversions on ECG and troponin-T of 6290 ng/L. Acute coronary syndrome treatment was initiated. The coronary angiography demonstrated tortuous calcified coronaries without any significant obstructive lesion. However, late dye acquisition images revealed a capillary blush originating from the diagonal branch of left anterior descending artery (figures 1 and and2)2) and the distal right coronary artery (figures 3 and and4)4) feeding into the ventricular cavity through intramural thebesian vein connections, almost producing a ventriculogram (figures 5 and and66).

Figure 1
The flow through the coronary artery fistula (thebesian veins) in the diagonal branch of left anterior descending artery is seen (in late dye acquisition images) as a capillary blush (marked with arrows) in the RAO cranial view. This flow is causing drainage ...
Figure 2
The flow through the coronary artery fistula (thebesian veins) in the diagonal branch of left anterior descending artery is seen (in late dye acquisition images) as a capillary blush (marked with arrows) in the RAO caudal view. This flow is causing drainage ...
Figure 3
The flow through the coronary artery fistula (thebesian veins) in the distal right coronary artery is seen (in late dye acquisition images) as a capillary blush (marked with arrows) in the LAO view. This flow is causing drainage of oxygenated blood directly ...
Figure 4
The flow through the coronary artery fistula (thebesian veins) in the distal right coronary artery is seen (in late dye acquisition images) as a capillary blush (marked with arrows) in the RAO cranial view. This flow is causing drainage of oxygenated ...
Figure 5
The flow of contrast through the thebesian veins into the ventricular cavity producing a ventriculogram (ventricle seen in systole).
Figure 6
The flow of contrast through the thebesian veins into the ventricular cavity producing a ventriculogram (ventricle seen in diastole).

This episode which otherwise would been an undetectable plaque event, turned out to be one of significant myocardial injury due to background presence of the ‘the coronary steal’ syndrome.

Persistence of embryonic coronary artery fistulas in form of diffuse vascular network directly draining oxygenated blood from the coronaries into the ventricles bypassing the myocardial capillary network are called thebesian veins. Coronary artery fistulas are rare (<0.2%1), remain silent and often discovered incidentally on coronary angiogram or ventriculography.2 They rarely become haemodynamically significant and become a non-atherosclerotic cause of angina via the coronary steal phenomenon.3 Case reports of steal phenomenon are reported in adults4 5 and neonates.6 A case of paradoxical exacerbation of myocardial ischaemia with nitrates increasing the ‘steal’ is reported.7 People may present with ischaemic ECG changes,4 8 positive troponin4 and even bacterial endocarditis.9 These malformations were also reported in a carrier of fragile X syndrome.10

Learning points

  • Non-atherosclerotic coronary arterial anomaly may be associated with myocardial ischaemia producing angina symptoms and troponin rise.
  • A good image for cardiology trainees to remember.

Footnotes

Contributors: RA prepared the manuscript while AG supervised the manuscript. JS is the consultant responsible for the patient.

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Stierle U, Giannitsis E, Sheikhzadeh A et al. Myocardial ischemia in generalized coronary artery-left ventricular microfistulae. Int J Cardiol 1998;63:47–52 doi:10.1016/S0167-5273(97)00280-5 [PubMed]
2. Judkins C, Yamen E Inadvertent thebesian vein cannulation during radial access ventriculography. JACC Cardiovasc Interv 2013;6:e9–10 doi:10.1016/j.jcin.2012.09.014 [PubMed]
3. Levin DC, Fellows KE, Abrams HL Hemodynamically significant primary anomalies of the coronary arteries. Angiographic aspects. Circulation 1978;58:25–34 doi:10.1161/01.CIR.58.1.25 [PubMed]
4. Chattopadhyay S, Wahab N, O'Reilly K Persistent thebesian veins presenting with myocardial ischemia. Can J Cardiol 2010;26:e31–2 doi:10.1016/S0828-282X(10)70345-7 [PMC free article] [PubMed]
5. Krishnan U, Schmitt M Images in cardiovascular medicine. Persistent thebesian sinusoids presenting as ischemic heart disease. Circulation 2008;117:e315–16 doi:10.1161/CIRCULATIONAHA.107.748863 [PubMed]
6. Skimming JW, Walls JT Congenital coronary artery fistula suggesting a “steal phenomenon” in a neonate. Pediatr Cardiol 1993;14:174–5 doi:10.1007/BF00795649 [PubMed]
7. Heper G, Kose S Increased myocardial ischemia during nitrate therapy caused by multiple coronary artery–left ventricle fistulae? Tex Heart Inst J 2005;32:50–2. [PMC free article] [PubMed]
8. Jung Y, Kim H, Yoon CH Severe form of persistent thebesian veins presenting as ischemic heart disease. Korean Circ J 2012;42:714–17 doi:10.4070/kcj.2012.42.10.714 [PMC free article] [PubMed]
9. Alkhulaifi AM, Horner SM, Pugsley WB et al. Coronary artery fistulas presenting with bacterial endocarditis. Ann Thorac Surg 1995;60:202–4 doi:10.1016/0003-4975(95)00037-L [PubMed]
10. Koganti S, Gunarathne A, Desai P et al. A rare type of ‘coronary arterial — left ventricular fistula’ via thebesian veins in a Fragile X syndrome carrier. Cardiol J 2011;18:318–19. [PubMed]

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