Balloon embolization of latrogenic aortocoronary arteriovenous fistula

Iatrogenic Aortocoronary Arteriovenous Fistula following Coronary Artery Bypass Surgery: A Case Report and Complete Review of the Literature

The case of a patient who presented with angina following a coronary artery bypass (CABG) operation during which the left internal mammary artery was inadvertently anastomosed to a cardiac vein is presented. The literature concerning previously reported cases of aortocoronary arteriovenous fistulas (ACAVF) due to inadvertent grafting of a coronary vein is reviewed and the significance of this complication is discussed. ACAVF due to inadvertent grafting of a coronary vein is a rare complication of CABG and may be a more common cause of graft failure than has previously been recognized. Distortion of cardiac anatomy, the presence of epicardial fat, and an intramyocardial course of the artery intended for grafting are predisposing factors. Some patients present with angina pectoris and heart failure whereas others have no symptoms. The diagnostic test of choice is coronary angiography. Cardiac MRI and CT have a limited role due to the smaller size and the more clearly defined course of these fistulas. Asymptomatic patients are simply observed since spontaneous closure of these fistulas is reported. Symptomatic patients can be treated with combined medical management and percutaneous methods.

Iatrogenic left internal mammary artery to great cardiac vein anastomosis treated with coil embolization

Inadvertent left internal mammary artery (LIMA)-great cardiac vein (GCV) anastomosis is a rare complication of coronary artery bypass graft surgery. Patients with iatrogenic aortocoronary fistula (ACF) were usually treated surgical repair, percutaneous embolic occlusion with coil or balloon. We report a case of iatrogenic LIMA to GCV anastomosis successfully treated with coil embolization and protected left main coronary intervention through the percutaneous transfemoral approach.

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.

Successful coil embolization with assistance of coronary stenting in an adult patient with a huge coronary arterial-right atrial fistula

A 55 year-old man with huge coronary artery fistula to the right atrium is presented. The Qp/Qs ratio was 1.6. We failed to place simultaneously three interlocking detachable coils for closing the fistula, because the coils were washed out into the right atrium. We deployed the coronary stent at the distal portion of the coronary artery. This procedure enabled us to anchor 7 electrically or interlocking detachable coils and to interrupt the shunt flow. A Doppler flow wire was useful to reveal instantaneously the extent of flow reduction even when contrast angiography was not performed in each procedure.

Iatrogenic left internal mammary artery–coronary vein anastomosis treated with covered stent deployment via retrograde percutaneous coronary sinus approach

OBJECTIVES

Percutaneous treatment of acquired coronary fistula with covered stent

BACKGROUND

Acquired aorto-coronary fistulae (ACF) is a rare complication of coronary artery bypass graft (CABG) surgery. Surgical repair has been generally recommended, but percutaneous techniques have also been described; coils were used primarily in smaller fistula while double umbrella or vascular occlusion devices were used in larger ones. To the best of our knowledge the use of coronary covered stent has never been reported. A 73-year-old man underwent CABG in November 2004 for unstable angina and left internal mammary artery (LIMA) was anastomosed to left anterior descending (LAD) coronary artery. Three months later he underwent a control angiogram to check for the reappearance of effort angina, which demonstrated an inadvertent LIMA-great cardiac vein (GCV) anastomosis. After discussions, an attempt to close the ACF with implantation of a covered stent was performed.

METHODS

Using a percutaneous right internal jugular vein approach, coronary sinus was selectively cannulated and a 0.014-in. coronary guide wire was advanced selectively to the GCV, then a covered stent was deployed across the anastomotic site, obtaining the immediate occlusion of the ACF.

RESULTS

No contrast medium flowed into the distal part of the GCV at the reinjection of the coronary sinus and a selective injection into LIMA showed the absence of flow through LIMA, confirming the occlusion of the anastomotic site.

CONCLUSIONS

We have demonstrated successful occlusion of an iatrogenic ACF by using percutaneous stenting of GCV with covered stent via coronary sinus approach, which seems to be technically less demanding, safer, and time sparing.

Closure of an iatrogenic aortocoronary arteriovenous fistula: transcatheter balloon embolization following failed coil embolization and salvage of coils that migrated into the coronary venous system

We report a 50-year-old patient with successful percutaneous closure of a large inadvertent surgical aortocoronary arteriovenous fistula (shunt flow: 1.8 L/min). With initial embolization of multiple coils, no lasting occlusion of the large fistula could be achieved. Above that, two coils migrated into the coronary venous system. Following rescue of the migrated coils through a retrograde coronary sinus approach, the fistula was occluded using a detachable balloon. Follow-up angiograms confirmed successful closure of the fistula. In contrast to coil embolization, use of a detachable balloon seems to be the appropriate technique for percutaneous closure of such fistulas.

Outcomes of transcatheter embolization in the treatment of coronary artery fistulas

Thirteen children (seven male) with coronary artery fistula underwent percutaneous transcatheter occlusion. The age range was 8 months to 14 years (mean, 6.3 years). The fistulas had their origins from the right coronary artery (six), from the left anterior descending coronary artery (three), and from the left circumflex coronary artery (four). Drainage was to the right ventricle (seven), the right atrium (three), and one each to the pulmonary artery, left atrium, and superior caval vein. The fistulas were closed with coils in 10 patients, a Rashkind double-umbrella device in 1 patient, and an Amplatzer Duct Occluder in 2 patients. Complete occlusion was achieved in 9 of 13 patients. Complications consisted of migration of coils in four and transient arrhythmias or changes in the resting electrocardiogram in four patients. Follow-up studies 1 to 31 months (mean, 14.6 months) after occlusion noted only four patients with trivial (clinically insignificant) residual shunts. Owing to various coronary fistula morphologies, transcatheter occlusion requires availability of different embolization techniques. Short-term follow-up supports persistent clinical efficacy and transcatheter closure techniques as the initial form of therapy.

Percutaneous occlusion of an iatrogenic aortosaphenous vein--coronary vein fistula via retrograde coronary sinus approach

Inadvertent aortosaphenous vein graft-coronary vein anastomosis during coronary bypass surgery is an uncommon complication. We describe a case of aortosaphenous vein side-to-side anastomosis to an obtuse marginal vein resulting in a large arteriovenous fistula and elective closure, using embolization coils delivered percutaneously via the coronary sinus. The clinical findings, interventional procedure, and follow-up are also presented, with a discussion of alternative techniques used previously to treat iatrogenic aortosaphenous vein graft venous fistulae.

Iatrogenic aorto-coronary venous fistula as a complication of coronary artery bypass surgery: patient report and review of the literature

We report a patient and review the literature of an unusual complication of coronary artery bypass graft surgery, an acquired aorto-coronary venous fistula. This report reviews the clinical presentation, physical findings, and management of this rare finding.

Transcatheter coil occlusion for treatment of left internal mammary-anterior descending artery steal phenomenon

A 60-yr-old female with previous bypass surgery including LIMA-LAD graft presented with unstable angina due to steal phenomenon caused by a large pectoral branch of LIMA. Transcatheter coil occlusion of the pectoral branch was successfully performed. This procedure should be considered in similar cases.

Combined PTCA and microcoil embolization of a left internal mammary artery graft

Internal mammary arteries are increasingly common conduits for coronary revascularization. Although infrequent, cardiologists are faced with a number of technical failures. We describe a case of combined PTCA to a LIMA insertion stenosis, along with coil embolization of a large unligated intercostal side branch. A complication of embolization is described along with angiographic follow-up.

Detachable balloon embolization of an iatrogenic aortocoronary arteriovenous fistula combined with aortocoronary bypass PTCA: a case report

Coronary artery bypass surgery was performed in a 54-year-old male, and one of the grafts was inadvertently sutured to the vena cordis magna instead of to the left anterior descending coronary artery (LAD). Four years later the patient observed a progression of symptoms including episodes of angina pectoris at rest. Coronary angiography showed stenosis of one of the bypass grafts and notable dilatation of an iatrogenic arteriovenous (A-V) fistula. The stenosed bypass graft was dilated and the A-V fistula occluded by use of a detachable balloon. Embolization was performed rather than surgery, as the LAD was found to be a poor surgical target. The patient's symptoms improved after the procedure; he was followed for 18 months during which time his condition remained stable.

Transcatheter closure of coronary artery fistulas

Transcatheter closure of a coronary artery fistula was undertaken in nine patients. There were three fistulas from the left circumflex coronary artery to the coronary sinus, three from the left anterior descending coronary artery to the right ventricular apex, two from the right coronary artery to the superior vena cava/right atrial junction and one fistula from the left circumflex artery to the pulmonary artery. The fistula was closed with Gianturco coils in six patients, a double-umbrella device in two and a combination of an umbrella and coils in one patient. All fistulas are completely occluded. Complications consisted of migration of two coils, one of which was retrieved, and a transient junctional tachycardia in one patient. In an additional three patients with multiple coronary artery fistulas, transcatheter occlusion was not attempted.

Closure of a coronary fistula with a transcatheter implantable coil

Large sized coronary artery fistulas are rare and diagnosed in only 0.05% of adult catheterized patients. Only a minority of these fistulas are operated upon. We describe a percutaneous technique to close a left coronary artery fistula draining into the right atrium in a 30-yr-old male patient. The fistula was closed by implantation of a trefoil coil, inserted through a catheter selectively advanced into the fistula.

Successful percutaneous closure of a complex coronary-to-pulmonary artery fistula using a detachable balloon: benefits of intra-procedural physiologic and angiographic assessment

A 48-yr-old woman presented with a loud continuous precordial murmur and symptoms of fatigue. Color-flow doppler imaging and nuclear magnetic resonance imaging failed to show the cause of the murmur. Diagnostic catheterization showed a large left anterior descending coronary artery to pulmonary artery fistula with impaired left ventricular wall motion. Two detachable balloons were deployed in the fistula with complete abolition of flow in the main fistula channel. A small parallel channel of the fistula, previously not appreciated due to vessel overlap, remained patent but had trivial flow as assessed by green-dye and oximetric techniques. The patient had immediate resolution of her symptoms and return of normal ventricular wall motion.