Transcatheter closure of a large coronary arteriovenous fistula using the new Amplatzer Duct Occluder

Role of transesophageal echocardiography in surgical retrieval of embolized amplatzer device and closure of coronary-cameral fistula

Congenital coronary artery fistula is an uncommon anomaly. Transcatheter coil embolization or Amplatzer vascular plug device closure of fistula is often done in symptomatic patients with safe accessibility to the feeding coronary artery. Embolization of Amplatzer vascular plug device is rare. We report an 11-year-old male child who presented to us with increasing shortness of breath for 7 years. He had a history of Amplatzer vascular plug device closure of right coronary–cameral fistula 8 years back. Echocardiography demonstrated a dilated aneurysmal right coronary artery with turbulent jet entering into the right ventricle (RV) and device embolized into the left pulmonary artery (LPA). Cardiac catheterization eventually confirmed the diagnosis. Surgical closure of fistula and retrieval of device was done using cardiopulmonary bypass. Intraoperatively transesophageal echocardiogram helped in localizing fistula opening in the RV below the anterior leaflet of tricuspid valve, continuous monitoring to prevent further distal embolization of the device during surgical handling, and assessment of completeness of repair of the fistula and LPA following retrieval of the device.

Large coronary artery fistula and patent ductus arteriosus: transcatheter closure with three PDA nitinol wire mesh occluders

Coronary artery fistulas (CAF) are the most common congenital anomaly of this vessel. We present the case of a 26-year-old man with two coexisting congenital cardiac defects: patent ductus arteriosus (PDA) and CAF. The patient 3 months earlier had the transcatheter PDA closed (type A, diameter 4 mm) with a 10/8 mm PDA nitinol wire mesh occluder. After the procedure he continued to have symptoms of fatigue and continuous murmur in the precordial region persisted. In angio-CT a large coronary fistula from the circumflex coronary artery with suspicion of multiple orifices to the right atrium was found. An arteriovenous wire loop was created (guidewire introduced from the aorta through the CAF was snared using a lasso catheter in the superior vena cava and exteriorized through the right femoral vein). Retrogradely an 8 F long sheath and delivery system was introduced to the end of the fistula and a 12/10 mm Cardio-O-Fix PDA occluder (Starway Comp, China, Beijing) was implanted, closing one orifice of the CAF. Another leak (orifice of CAF – 3.5 mm diameter) was closed using a similar technique with a 10/8 mm PDA Cardio-O-Fix device. Complete closure of the coronary artery fistula and disappearance of the heart murmur were observed after the procedure. The patient was discharged home 4 days later on acetylsalicylic acid 150 mg/day. During 6 months of follow-up he was doing well without any complaints or pathological symptoms. In control angio-CT performed 3 months after the procedure complete closure of the CAF was confirmed.

State of the art catheter interventions in adults with congenital heart disease

Catheter interventions in adults with congenital heart disease have rapidly advanced. Transcatheter valve repair and replacement techniques have been added to the existing spectrum of well-established procedures. This review summarizes current transcatheter management strategies for congenital cardiac anomalies seen in the adult population.

Transcatheter closure of large congenital coronary-cameral fistulae with Amplatzer devices

OBJECTIVES

To report on the methods and results of treatment of large congenital coronary-cameral fistulae by transcatheter closure with Amplatzer devices.

BACKGROUND

Large coronary-cameral fistulae cause a steal phenomenon from the normal coronary circulation. Surgical closure is an option. However, transcatheter methods allow for temporary occlusion, definition of anatomy, and online assessment of successful closure. Amplatzer devices are compact occluders that can be fully delivered, collapsed, and repositioned until a satisfactory position is attained.

METHODS

Coronary and fistula anatomy were defined by selective coronary angiography with or without temporary occlusion. Device closure of the fistula was performed at the most distal point accessible, often from the cameral side using an arteriovenous loop method.

RESULTS

Ten patients of median age 2.6 years (0.5-52.2) and weight 14.4 kg (6.1-67) underwent an attempt at transcatheter closure of a large fistula. In nine patients, the fistula was closed successfully with a device. There were no complications.

CONCLUSIONS

Transcatheter closure of coronary-cameral fistula with Amplatzer devices is safe and effective.

Transcatheter closure of coronary artery fistulae using the Amplatzer Duct Occluder

OBJECTIVE

The aim of this study is to report our experience using the Amplatzer Duct Occluder (ADO) for occlusion of significant coronary artery fistulae (CAF).

BACKGROUND

Transcatheter closure of CAF with coils is well described. Use of newer devices may offer advantages such as improved control of device placement, use of a single instead of multiple devices, and high rates of occlusion.

METHODS

A retrospective review of all patients catheterized for CAF from July 2002 through August 2005 was performed.

RESULTS

Thirteen patients with CAF underwent cardiac catheterization, of which a total of 6 patients had ADO placement in CAF (age, 21 days to 56 years; median age, 4.3 years and weight, 3.8 kg to 74.6 kg; median weight, 13.3 kg). An arteriovenous wire loop was used to advance a long sheath antegrade to deploy the ADO in the CAF. Immediate and short-term outcomes (follow-up, 3 months to 14 months; median follow-up, 8.5 months) demonstrated complete CAF occlusion in 5 patients and minimal residual shunt in 1 patient (who had resolution of right atrial and right ventricular enlargement). On follow-up clinical evaluation, all 6 patients had absence of fistula-related murmurs, and 2 previously symptomatic patients had resolution of congestive heart failure symptoms. Early complications included transient palpitations and atrial arrhythmia in the 2 oldest patients (52 and 56 years old).

CONCLUSIONS

Use of the ADO is applicable for transcatheter closure of significant CAF. Advantages of using the ADO include the antegrade approach, use of a single device, and effective CAF occlusion.

Transcatheter occlusion of the isolated scimitar vein anomaly camouflaged under dual pulmonary venous drainage of the right lung by the Amplatzer Ductal Occluder

A 3.5-year-old girl, who presented recurrent pneumonia without discernible cyanosis or desaturation due to isolated scimitar vein anomaly camouflaged by dual pulmonary venous drainage of the right lung, underwent anterograde transvenous occlusion for this abnormal vessel successfully by the Amplatzer Ductal Occluder at 4 years old.

Coronary artery fistulae

Coronary artery fistulae are abnormal communications between a coronary artery and a cardiac chamber or major vessel (vena cava, pulmonary veins, pulmonary artery). They are usually diagnosed by coronary arteriography. Clinical presentations are variable depending on the type of fistula, shunt volume, site of the shunt, and presence of other cardiac conditions. In this article, we review the literature regarding etiology, incidence, clinical manifestation, image studies, and management.

Percutaneous interventional closure of large pulmonary arteriovenous fistulas with the amplatzer duct occluder

Large pulmonary arteriovenous fistulas (PAVFs) are difficult for transcatheter treatment. This report presents 5 patients aged 3 to 73 years with large PAVFs who underwent successful transcatheter closure with the Amplatzer duct occluder (ADO), designed for the occlusion of patent duct arteriosus. The procedures were performed without complications and provided sustained improvement in arterial oxygen saturation and exercise tolerance on follow-up examination in all patients. The transcatheter closure of large PAVFs with the ADO is effective and can eliminate the need for surgical intervention. The newly designed Amplatzer vascular plug is undergoing clinical trials.

Review of an institutional experience of coronary arterial fistulas in childhood set in context of review of the literature

Coronary artery fistulas are uncommon in children. We conducted a retrospective review of the case notes of 17 children who presented to our institution with the diagnosis of a coronary fistula since 1970. Their median age was 2.3 years. In five patients, there were associated congenital cardiac anomalies, with four having these as part of the spectrum of tetralogy of Fallot. Surgical correction was performed in nine patients, while in five closure was achieved using percutaneous embolization with coils. No complications or deaths were encountered related to the treatments chosen. In two patients, further procedures were needed to close residual fistulas. The median follow-up was 16 years, and on echocardiography, all fistulas appeared to be successfully closed, albeit that we lost three patients to follow up. We also conducted a review of 426 cases of coronary fistulas reported in children in the English literature. We have compared these findings with our institutional experience.

Microcoil embolization for treatment of a right coronary arteriovenous fistula

A patient initially presented with anginal symptoms and a positive stress thallium test. An arteriovenous malformation in the right coronary artery causing a suspected coronary "steal syndrome" was subsequently discovered. This was treated with a microcoil embolization technique in lieu of the traditional surgical approach and this technique is described in detail. The patient had successful clinical, nuclear, and angiographic outcomes.

Techniques and applications of transcatheter embolization procedures in pediatric cardiology

Transcatheter embolization of congenital or acquired superfluous vascular structure has become routine procedures performed by interventional pediatric cardiologists. Embolization procedure is often part of a collaborative effort with cardiac surgeons to palliate complex congenital heart defect, such as in embolizing aortopulmonary collateral arteries in patient with single ventricle physiology. In other cases, the procedure is the definitive treatment as in embolizing coronary artery fistula. Pediatric cardiologists performing embolization procedures should be familiar with available technologies as well as understand the underlying cardiac anatomy and pathophysiology. This article provides a comprehensive review of presently available embolization agents and technologies. Some of the technologies are used only by interventional radiologists but may be useful to pediatric cardiologists. Specific clinical applications in pediatric cardiology are also discussed with summary of current literature. With continue advancement in transcatheter technology and operator expertise, all unwanted vascular communication should be amenable to transcatheter embolization.

Neonatal transcatheter occlusion of a large coronary artery fistula with Amplatzer duct occluder

A large fistula from the right coronary artery to the right atrium was diagnosed in a fetus at 22 weeks of gestation. Following delivery, the baby developed cardiac failure. The fistula was occluded at 3 weeks of age by transcatheter implantation of an Amplatzer duct occluder. Large coronary fistulas can be closed safely with a device even at this early age. Vigilance for ischemic events is required following implantation because of the rare possibility of thrombus extension proximally into the native coronary artery or spasm of the coronary artery.

Percutaneous closure of a giant coronary arteriovenous fistula using multiple devices in a 12-day-old neonate

Coronary arteriovenous fistulas (CAVFs) are uncommon in children and are rarely reported in neonates. Larger fistulas usually require either surgical closure or percutaneous closure using a variety of different devices. Device closure of large fistulas in the immediate neonatal period has not been reported. We report the first case of a gigantic CAVF in a 12-day-old neonate (2.4 kg) where successful device closure was achieved in a staged approach using a 12 mm Amplatzer muscular VSD device, seven flipper coils, a 10/8 mm Amplatzer duct occluder device, as well as a 9 mm Gianturco Grifka vascular occlusion device. No complications were encountered and the patient was subsequently weaned off the ventilator.

Retrograde transcatheter coil embolization of congenital coronary artery fistulas in infants and young children

We report the success of transcatheter coil embolization of congenital coronary artery fistulas in infants and young children, primarily using a retrograde coaxial delivery system. Transcatheter coil embolization of coronary artery fistulas has been used successfully in the adult population with limited reports in the pediatric population, especially in infants. Ten patients underwent transcatheter coil embolization of congenital coronary artery fistulas between January 1993 and August 1999. The median age was 4.5 years (ranging from 5 weeks to 9.8 years). Coils were delivered exclusively using a retrograde arterial approach in 8 of 10 patients. A coaxial system was used in 8 patients. Angiography immediately after placement of coils revealed no residual shunt in any patient. Recent follow-up evaluation is available for 9 patients (median duration of follow-up, 7.9 months). Echocardiographic and clinical evaluations show complete occlusion in 8 of 9 patients. All patients are asymptomatic with normalization of chamber dimensions and coronary artery caliber. Transcatheter coil embolization of congenital coronary artery fistulas can be performed safely and successfully in infants and young children. The use of a retrograde approach and coaxial system is safe and effective and may provide better accuracy, stability and precision for placement of coils.

Percutaneous, Catheter-Based Coil Embolization of Coronary Fistula:

A 55-year-old male with angina-like chest pain and positive thallium-scintigraphy was admitted to our hospital. Cardiac catheterization was performed for suspected coronary artery disease. The coronary angiogram showed no significant epicardial stenosis, but a large coronary fistula, connecting the left anterior descending artery with the pulmonary artery. Swan-Ganz catheter measurements, intracoronary Doppler, and quantitative coronary angiography were used to determine cardiac output, coronary blood flow, and coronary-to-pulmonary artery shunt fraction. These measurements showed a hyperdynamic cardiac output of 17 L/min, a coronary blood flow of 140 mL/min in the left anterior descending coronary artery with an estimated shunt fraction of 58% into the pulmonary circulation. Percutaneous, catheter-based coil embolization was performed to occlude the fistula. After embolization of one coil, coronary angiography showed the fistula's stump only. Cardiac output (9 L/min) and coronary blood flow (48 mL/min) were almost normalized. The patient was discharged from the hospital the day after the procedure. After a 6-month follow-up, there were still no complaints, angina-like symptoms or signs of myocardial ischemia in stress tests.

Percutaneous closure of a ruptured sinus of Valsalva aneurysm using the Amplatzer Duct Occluder

Sinus of Valsalva aneurysms are rare congenital anomalies. When they rupture, they can lead to the development of biventricular failure as a result of systemic-pulmonary shunting. Surgical repair has been the traditional treatment for these aneurysms. We present a case of a 54 year old man in whom a ruptured sinus of Valsalva aneurysm was successfully closed using a catheter-based approach with the Amplatzer Duct Occluder.

Transcatheter embolization treatment of coronary arteriovenous fistulas

Transcatheter coronary arteriovenous fistula occlusion was performed in 5 children with a median age of 5.3 years (range, 0.7 to 11 years). Surgical ligation had been carried out previously in one case, but recanalization occurred during follow-up. Dilation of the feeding artery was observed in 4 patients, with an additional aneurysm of the coronary artery in one of these. Occlusion was attempted three times in 1 patient, twice in 2, and once in the other 2. Detachable balloons were used in 2 procedures, and controlled-release coils in 3. Complete occlusion of the fistula was achieved in 4 patients. In the 5th patient, occlusion of one of two fistulas was unsuccessful, and mild to moderate aortic valve insufficiency developed due to catheter manipulation. Our experience indicates that transcatheter occlusion of congenital coronary arteriovenous fistula is at least as successful as surgical intervention. Multiple occlusion procedures can be avoided by selecting the optimal technique in each case.

Closure of the fenestration in the extracardiac Fontan with the Amplatzer duct occluder device

We report the successful use of the Amplatzer duct occluder for the delayed closure of the fenestration in three patients who underwent an extracardiac modified Fontan procedure. At the moment of closure, the patients were 5.5, 2.7, and 3 years old (29 months, 3 months, and 14 months after the Fontan procedure, respectively). Immediate full occlusion was achieved in all cases. In addition, arterial saturation increased significantly (> 5%) with no hemodynamic deterioration. There were no complications during or after the procedure, and the patients were discharged in good conditions the day after and with uneventful follow-up. In conclusion, the Amplatzer duct is safe and effective for the closure of the fenestration in the extracardiac Fontan. Cathet Cardiovasc Intervent 2001;54:88-92.

Use of a 0.052" Gianturco coil to embolize a persistent right superior vena cava following extracardiac total cavopulmonary connection

A persistent right superior vena following extracardiac total cavopulmonary connection was occluded using a 0.052" Gianturco coil combined with a 3 Fr biopsy forceps. Controlled delivery of a 0.052" Gianturco coil is a safe and effective procedure to occlude a large anomalous vessel other than a large persistent arterial duct.

Successful occlusion of a coronary arteriovenous fistula using an Amplatzer duct occluder

In an 11-year old boy with a large coronary arteriovenous fistula between the left coronary artery and the right atrium, we achieved successful closure using a 10-8 Amplatzer Duct Occluder introduced from the right internal jugular vein. Angiography 6 weeks later showed complete occlusion of the fistula, with normal opacification of the left coronary arterial system. This technique may be used as an alternative to coils and surgery in selected patients.

New interventional therapeutic approach for dual drainage of the scimitar vein

A patient with scimitar syndrome and dual drainage of a right-sided scimitar vein into the inferior vena cava and the left atrium underwent coil occlusion of the right aortopulmonary collateral artery and device occlusion of the lower scimitar vein drainage, leaving it flowing solely into the left atrium.

Severe haemolysis after transcatheter closure of a patent arterial duct with the new Amplatzer duct occluder

Severe mechanical haemolysis occurred in an 11-month-old boy after implantation of the new Amplatzer duct occluder. Temporary balloon occlusion of the aortic ampulla was performed 4 days after the initial procedure leading to prompt abolition of the haemolysis.

Transcatheter closure of apical ventricular muscular septal defect combined with arterial switch operation in a newborn infant

This report describes a case of transposition of the great arteries and apical muscular ventricular septal defect in a newborn infant successfully treated by transcatheter closure of the septal defect with the Amplatzer duct occluder device followed by an arterial-switch operation within the first 2 weeks of life. Cathet. Cardiovasc. Intervent. 49:173-176, 2000.

Transcatheter closure of a large coronary artery fistula with the Amplatzer duct occluder

We report the successful percutaneous closure of a large coronary artery fistula from the obtuse marginal artery to the right ventricle in an 8-month-old boy using the Amplatzer duct occluder. The device was positioned and deployed via the venous system, using a guidewire that had been advanced via the aorta, coronary artery, and fistula to the venous circulation. Cathet. Cardiovasc. Intervent. 48:188-190, 1999.