Transcatheter closure of coronary artery fistula: A 21‐year experience

Transcatheter closure of multiple coronary artery fistulas: a coronary computed tomography angiography-based anatomic classification

INTRODUCTION AND OBJECTIVES

This study aimed to retrospectively analyze the anatomical characteristics and classification of multiple coronary artery fistulas (MCAFs), and to compare the outcomes of transcatheter closure between MCAFs and single fistulas.

METHODS

All patients who underwent attempts at transcatheter closure of coronary artery fistulas (CAFs) at Fuwai Hospital from 2010 to 2023 were retrospectively reviewed. Patients were categorized into single fistula and MCAFs groups, and anatomical characteristics and transcatheter closure outcomes were compared between the 2 groups.

RESULTS

This retrospective study included 146 patients who underwent attempted transcatheter closure of CAFs, with a 14.38% failure rate. Among the 146 patients with CAFs, 32.19% were identified as having MCAFs, with types I, II, and III constituting 40.43%, 42.55%, and 17.02%, respectively. Unlike single fistulas, which predominantly originated from the right coronary artery and terminated in the left ventricle, MCAFs mainly had simultaneous origins from the right coronary artery and left anterior descending artery (29.79%), and predominantly drained into the pulmonary artery (70.21%), with a notable prevalence of plexus-like morphology (38.3% vs 2.02%, P<.001). The success rate of transcatheter closure was significantly lower for multiple fistulas compared with single fistula (64.29% vs 84.34%, P=.011). Multivariate regression analysis indicated that the risk of closure failure for MCAFs was 2.64 times that of single fistulas.

CONCLUSIONS

MCAFs are common among CAFs and can be classified into 3 types based on the number and location of their origins and terminations. The risk of failure of transcatheter closure is significantly higher in MCAFs than in single fistulas.

Three-Decade Experience With Management of Coronary Artery Fistulas in Children

BACKGROUND

The treatment approach for coronary artery fistulas (CAFs) is debatable, and long-term outcomes are unknown.

METHODS

This was a retrospective institutional data review of children in whom echocardiographically suspected CAFs were confirmed during cardiac catheterisation from 1997 to 2023. Treatment approach and outcomes were assessed.

RESULTS

We identified 94 CAFs in 78 patients (42.3% male), median age 3.4 years (interquartile range [IQR] 0.9-6.6 y). Twenty-five patients (32%) had other congenital anomalies; 41 (78.8%) of the 52 patients with isolated CAFs were asymptomatic. The most common site of CAF origin and drainage was the left system (62.8%) and right cardiac cavities (80.8%). Overall median follow-up was 101 months (IQR 41-185 mo); 23 patients (29.5%) with 35 (37.2%) small or nonshunting CAFs had conservative management, and 20 (87%) of those 23 patients had an uneventful follow-up; 8 patients (10.2%) with 9 (9.6%) complex CAFs were directly sent for surgery; 1 patient had early surgical patch failure needing surgical reintervention; 47 patients (60.3%) had catheter closure of 50 (53.2%) medium- or large-sized CAFs with the use of coils (30%), vascular plugs (20%), nitinol duct occluders (40%), or material combination (10%). Six serious complications occurred. Two of the 3 patients with unsuccessful catheter procedures had subsequent surgeries. Two of the 3 patients with mild shunts had successful redo closures. One asymptomatic patient had recanalisation after 12 years and is under watchful observation.

CONCLUSIONS

CAFs have various anatomies and clinical presentations. Transcatheter closure is effective in carefully selected patients but is not complication free. Surgery is a valuable up-front option in complex CAFs or bailout of unsuccessful transcatheter closures, although it is not frequently used.

Coronary artery fistula following surgical myectomy for hypertrophic obstructive cardiomyopathy: a case report

Background

Coronary artery fistula is a rare, but recognized complication of surgical myectomy. Although most communicate with the right heart, a large fistula into the left ventricular cavity may result in a shunt haemodynamically analogous to aortic regurgitation. Understanding the variable presentation of iatrogenic coronary fistulae and the optimal evaluation strategy is critical to obtaining a timely diagnosis and instituting treatment.

Case summary

We report the case of a 57-year-old renal transplant recipient admitted for evaluation of presyncope, one-year post-surgical myectomy for hypertrophic obstructive cardiomyopathy. An iatrogenic coronary artery fistula was suspected by transthoracic echocardiography, and later confirmed with both non-invasive and invasive coronary angiography.

Discussion

We highlight various cardiac imaging modalities that confirmed the diagnosis of coronary artery fistula and helped to determine the clinical significance. We report the tailored approach often required to determine the anatomic and haemodynamic characteristics of coronary fistulae and outline potential management strategies.

Coronary Artery Aneurysms, Arteriovenous Malformations, and Spontaneous Dissections-A Review of the Evidence

BACKGROUND

Coronary artery aneurysms (CAAs), coronary arteriovenous malformations (CAVMs), and spontaneous coronary artery dissections (SCADs) are rare clinical entities, and much is unknown about their natural history, prognosis, and management.

METHODS

A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed in March 2023 to identify published papers related to CAAs, CAVMs, and SCADs.

RESULTS

CAAs are found in 0.3% to 12% of patients undergoing angiography and are often associated with coronary atherosclerosis. They are usually asymptomatic but can be complicated by thrombosis in up to 4.8% of patients and rarely by rupture (0.2%). CAAs can be managed medically, percutaneously with stents or coil embolization, and surgically. The most common surgical procedure is ligation of the aneurysm, followed by coronary artery bypass grafting. The incidence of CAVMs is 0.1% to 0.2% in patients undergoing angiography, and they are most likely associated with congenital abnormal development of the coronary vessels. The diagnosis of CAVMs is usually incidental. Surgical or percutaneous intervention is indicated for patients with large CAVMs, which carry a potential risk of myocardial infarction. SCADs represent 1% to 4% of all acute coronary syndromes and typically affect young women. SCADs are strongly correlated with pregnancy, suggesting the role of sex hormones in their pathogenesis. Conservative management of SCAD is preferred for stable patients without signs of ischemia as spontaneous resolution is frequently reported. Unstable patients should undergo revascularization either percutaneously or with coronary artery bypass grafting.

CONCLUSIONS

Further evidence regarding the management of these rare diseases is needed and can ideally be derived from multicenter collaborations.

Prevalence and characteristics of coronary artery fistulas among 20 259 patients undergoing invasive coronary angiography

BACKGROUND

Coronary artery fistula (CAF) is a rare coronary anomaly. This study aimed to investigate the prevalence, clinical features, and imaging characteristics of CAF among patients undergoing coronary angiography (CAG).

METHOD

This was a retrospective study including 20 259 consecutive patients (12 458 were male) who underwent CAG at our institution from September 2018 to March 2023. Electronic angiography records were reviewed, and a total of 86 (0.42%) CAF patients were enrolled and analyzed.

RESULT

Of the 86 CAF patients, 42 (49%) were male. Thus, the prevalence of CAF for males and females was 0.34% and 0.56%, respectively. Arrhythmia, left ventricular (LV) hypertrophy, LV dilation, and LV systolic dysfunction were observed in 38, 25, 10 and 5 cases, respectively. Among the 86 CAF patients, a total of 117 CAFs were detected. 61 (71%) patients had a single CAF, and the remaining 25 (29%) patients had multiple CAFs. Of the 117 CAFs, the most common origins and terminations were the left anterior descending artery (n = 50) and the pulmonary artery (n = 73), respectively. The CAF diameters were greatly varied, ranging from unmeasurable to 7.8 mm, and 22 (18%) CAFs were larger than 3 mm.

CONCLUSION

In the present study, the prevalence of CAF was 0.42% with a female predilection. Arrhythmia, LV remodeling and dysfunction were common. Seventy-one percent of patients had a single CAF. The left anterior descending artery and the pulmonary artery were the most common origin and termination of CAFs, respectively. Most CAFs were small, and 18% of CAFs were larger than 3 mm.

Coils embolization use for coronary procedures: Basics, indications, and techniques

The use of coils is fundamental in interventional cardiology and can be lifesaving in selected settings. Coils are classified by their materials into bare metal, fiber coated, and hydrogel coated, or by the deliverability method into, pushable or detachable coils. Coils are delivered through microcatheters and the choice of coil size is important to ensure compatibility with the inner diameter of the delivery catheter, firstly to be able to deliver and secondly to prevent the coil from being stuck and damaged. Clinically, coils are used in either acute or in elective setting. The most important acute indication is typically the sealing coronary perforation. In the elective settings, coils can be used for the treatment of certain congenital cardiac abnormalities, aneurysms, fistulas or in the treatment of arterial side branch steal syndrome after CABG. Coils must always be delivered under fluoroscopy guidance. There are some associated complications with coils that can be acute or chronic, that nictitates regular followed-up. There is a need for education, training and regular workshops with hands-on to build the experience to use coils in situations that are infrequently encountered.

Surgical Management of a Large Right Coronary Artery to Left Ventricle Fistula in a Neonate: A Case Report

A fistula from the right coronary artery draining into the left ventricle is a rare form of coronary artery fistula. Here, we describe the case of a symptomatic neonate with a large fistula of this type. The neonate was successfully treated with surgical closure of the fistula.

Case report: Transcatheter closure of a giant and tortuous right coronary artery to right ventricle fistula in an infant

Congenital coronary artery fistulas (CAFs) are an uncommon congenital anomaly. While most patients are asymptomatic, life-threatening events including sudden death, myocardial ischemia, heart failure, infective endocarditis, and rupture of aneurysm may occur. Surgical ligation was once the standard choice of management of CAFs in the past. However, transcatheter closure of CAFs has become an emerging alternative to surgery in patients with suitable anatomy. We reported a 7-month-old infant with a giant and tortuous CAF that originated from the distal right coronary artery and drained into the right ventricle, and was successfully treated by transcatheter closure with an Amplatzer ductus occluder.

Embolization of vascular abnormalities in children with congenital heart diseases using medtronic micro vascular plugs

This study aimed at evaluating our experience with Micro Vascular Plug (MVP) for embolization of vascular abnormalities in children with congenital heart diseases (CHDs). MVP is one of the most recent additions to the armamentarium for peripheral embolization. Data on its use in congenital cardiology are scarce. Medical records of children with CHDs who had embolizations with MVPs between April 2015 and September 2020 were reviewed. Immediate and follow-up data were assessed. A total of 153 patients underwent 172 procedures during which 240 embolizations using 259 MVPs were attempted. Median age and weight were 34.9 months (IQR, 4-75 months) and 12.5 kg (IQR, 4.8-19.4 kg), respectively. Targets were abnormal systemic arteries (n = 163), patent arterial ducts (n = 26), venous (n = 45), and coronary-cameral fistulas (n = 6). Median vessel diameter was 3.3 mm (IQR, 2.5-4 mm). Veins were larger than arteries (2.3 mm > 2.1 mm, p < 0.01). MVPs were implanted in narrower diameters compared to manufacturer's recommendations. Compared to veins, solitary implanted MVPs in arteries were additionally oversized at 12.4%, 5.1%, and 7.9% for MVP-3Q, 5Q, and 7Q, respectively. Additional occlusion material (16.7%) and 2 MVPs (5.8%) were needed at the same site for complete closure. Implantation and procedure success rates were 99.2% and 96.7%, respectively. Five complications were treated percutaneously (n = 4) and surgically (n = 1). Efficacy of vascular embolization using MVPs was demonstrated in the largest cohort of children with CHDs and a variety of clinical settings. Immediate and stable closure is obtained with a single device in most cases. Detailed device selection chart according to vessel type and diameter is proposed to achieve intended outcomes.

Case Report: Coronary-Pulmonary Fistula Closure by Percutaneous Approach: Learning From Mistakes

Coronary-pulmonary artery fistulas (CPAF) are congenital vascular anomalies detected incidentally in most cases. When a significant left-right shunt exists, surgical, or percutaneous treatment is indicated. We describe a challenging case of CPAF closure, by percutaneous approach, in a patient symptomatic for dyspnea and evidence of a significant left-right shunt. A first attempt to close the fistula was performed implanting a vascular plug but it quickly embolized. The plug was successfully retrieved. In a second attempt, we deployed several coils before implanting the vascular plug with total closure of the fistula. The combination of plugs and coils is associated with a higher success rate of closure.

Utilization and outcomes of transcatheter coil embolization for various coronary artery lesions: Single-center 12-year experience

OBJECTIVE

Determining the outcomes of transcatheter coil embolization (TCE) for several coronary artery lesions.

BACKGROUND

TCE has been used as a treatment modality for various lesions in the coronary circulation. However, data on the efficacy and safety of TCE to treat coronary artery fistula (CAF), left internal mammary artery (LIMA) side-branch, coronary artery perforation (CAP), coronary artery aneurysm (CAA), and coronary artery pseudoaneurysm (CAPA) are limited.

METHODS

We conducted a retrospective, descriptive analysis of all TCE devices in coronary lesions at our center from 2007 to 2019. Forty-one studied lesions included 25 CAF, 7 LIMA side-branch, 5 CAP, 2 CAA, and 2 CAPA. Short- and 1-year mortality and hospital readmission were reported, in addition to coil-related complications and procedural success.

RESULTS

The utilization rate of TCE in coronary artery lesions at our center was found to be 33.8 per 100,000 percutaneous coronary intervention procedures over 12 years. Successful angiographic closure was achieved in 37 out of 41 (87.8%) cases (88, 100, 60, 100, and 100% of CAF, LIMA side-branch, CAP, CAA, and CAPA, respectively). No adverse events were directly related to TCE among the LIMA, CAA, and CAPA cases, and only one patient with CAF required reintervention at 3 months due to coil migration.

CONCLUSIONS

Coil embolization in our institution was safe and effective in treating different coronary circulation abnormalities with a 87.8% overall success rate. Further study on the use of vascular plug devices in cases such as CAF or LIMA side-branch would be beneficial to understand the treatment options better.

Coronary Artery Fistulas: A Review of the Current and Future Roles of Imaging

Coronary artery fistulas are uncommon but clinically important entities that may produce symptoms and significant complications such as angina, myocardial infarction, coronary artery aneurysm formation, and congestive heart failure. Multiple fistula types have been recognized, and classification uses factors such as etiology, coronary artery origin, and drainage site. Both invasive and noninvasive imaging play an important role in the management and treatment of these patients, and often times, more than one modality is necessary for comprehensive evaluation of coronary fistulas. Recent advances in both functional and anatomic imaging will likely also play a growing role in fistula evaluation. The purpose of this article is to review the classification, pathophysiology, clinical presentations, imaging findings, treatment, and future imaging directions of coronary artery fistulas.

Left Main Coronary Artery to Superior Vena Cava Fistula Unmasked by Endarteritis

Coronary artery fistulas are rare vascular malformations that can present with a broad range of symptoms. We present a case of a left main coronary artery to superior vena cava fistula that was discovered during a work-up for sepsis. A multidisciplinary approach is crucial for successful management of these vascular malformations. (Level of Difficulty: Beginner.)

Transcatheter Occlusion of a Giant Coronary Artery Fistula in a Neonate

BACKGROUND Although large coronary artery fistulas are uncommon; they lead to substantial over-circulation in the pulmonary vascular beds and left heart system. Fistula occlusions are achieved via surgical or transcatheter technique; however, reports on successful outcomes of transcatheter treatment during the neonatal period are limited. CASE REPORT A female infant was born at the gestational age of 37 weeks with a birth weight of 2615 grams via normal vaginal delivery. Cardiac auscultation revealed a loud continuous murmur emanating from the fourth right intercostal space. A right coronary artery-to-right ventricle fistula was confirmed using transthoracic echocardiography. The newborn developed respiratory distress 3 days after birth and was administered continuous positive airway pressure to assist breathing. On day 8, the ventilator was used through tracheal intubation due to gradual worsening of dyspnea. A 6-mm Amplatzer Vascular Plug 4 (AGA Medical Corporation, Plymouth, MN) was chosen, as the minimum diameter of the coronary artery fistula was 5 mm. In view of the risk of myocardial ischemia with additional devices, the procedure was stopped despite persistent shunting. The newborn's clinical condition significantly improved following the procedure and she was eventually weaned off ventilator support. CONCLUSIONS A self-expanding occlusion device was useful for relieving this life-threatening condition. Complete elimination of shunting is not always necessary, to avoid compromising myocardial circulation.

Coronary Artery Fistulas: Indications, Techniques, Outcomes, and Complications of Transcatheter Fistula Closure

Coronary artery fistulas (CAFs) are rare coronary anomalies that are usually diagnosed incidentally with cardiac imaging. Small CAFs are generally asymptomatic and can close over time, while some untreated medium or large CAFs can enlarge, leading to clinical sequelae such as cardiac chamber enlargement or myocardial ischemia. With the advancement of transcatheter equipment and techniques, CAFs have been increasingly closed using a percutaneous approach. However, the procedure is not free of limitations given the risk for myocardial infarction, device embolization, and fistula recanalization. In this review, the authors illustrate the contemporary procedural considerations, techniques, and outcomes of transcatheter CAF closure.

A case report of coronary pulmonary artery fistula detected by transthoracic echocardiography in an elderly patient with dyspnea

Coronary pulmonary artery fistula (CPAF) is a rare entity in the population. It may present with multiple clinical settings and in various age ranges. Invasive coronary angiography (ICA), coronary computed tomography angiography (CCTA), and transthoracic echocardiography (TTE) have been reported as diagnostic tools for CPAF. Among them, TTE is rarely capable of identifying CPAF. There is no current treatment guideline as some of the interventional therapies are effective yet controversial. The therapy therefore should be individualized. We report a case of CPAF accidentally detected by TTE in a 93-year-old female who presented with acute respiratory distress on the setting of community-acquired pneumonia, diastolic heart failure, ischemic heart disease, pulmonary hypertension, chronic kidney disease, and hypertension. The patient presented with orthopnea, fever, bilateral pleuritic chest pain, and productive cough with yellowish sputum for 7 days. She had no previous chest trauma or surgical intervention. TTE demonstrated the tortuous enlargement of left coronary artery which drains into the pulmonary arterial trunk right above the pulmonary valve. As the patient was in advanced age with multiple comorbidities; we offered a conservative management including diuretic, oxygen therapy, antibiotic, antiplatelet, and statin. She recovered following a 13-day hospitalization. To our knowledge, this is the oldest case report of suspected congenital CPAF which is particularly detected by TTE.

Coronary Artery Fistula

Coronary artery fistula (CAF) is an abnormal connection between a coronary artery and a heart chamber resulting in left-to-right shunt. A large CAF was an unexpected cause of heart failure in a 58-year-old woman who underwent transcatheter closure of the CAF with improvement in symptoms but complicated by myocardial infarction. (Level of Difficulty: Beginner.)