Acute Coronary Syndrome Following Percutaneous Closure of a Coronary Artery Fistula: The essential anticoagulation management – a case report

Case summary We report the case of a previously healthy 19-year-old woman with a large left coronary trunk–to–right atrium fistula, managed by percutaneous closure. Post-procedural antithrombotic therapy included apixaban and low-dose aspirin. One month later, the patient developed severe metrorrhagia with no identifiable organic cause, prompting unilateral modification of antithrombotic therapy without multidisciplinary discussion. Two months post-intervention, she presented with an acute ST-segment elevation myocardial infarction (STEMI), likely resulting from thrombus formation at the prosthesis site. Coronary flow of the left anterior descending artery was restored by successful thromboaspiration without stenting. Discussion This case highlights that any modification of antithrombotic therapy following percutaneous fistula closure must result from a thorough multidisciplinary discussion, carefully balancing bleeding risk against the potentially fatal consequences of thromboembolic events.