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, 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.