Transcatheter embolization of coronary artery fistula with controlled release coils

Long-term outcome of interventional approaches for treatment of coronary artery fistulas: a retrospective cohort study in a great referral center

BACKGROUND

Despite the spontaneous regression of many cases of coronary artery fistulas (CAFs), symptomatic patients or cases with severe shunting may require therapeutic interventions. In the present study, we aimed to assess the outcome of treatment of CAFs using interventional approaches.

METHODS

This retrospective cohort study was performed on 29 patients with CAFs that were referred to our tertiary center between 2009 and 2019. Baseline characteristics were collected by reviewing the hospital files, and the patients were followed up to assess long-term outcomes with a mean follow-up of 3.3 years.

RESULTS

Overall, in 29 patients in our cohort study, 82.9% suffered from isolated CAFs and in the remaining cases, concurrent congenital abnormalities did exist. For treatment, coils (Cook, Pfm, Ev3) were used in 79.3%, ADO II(AGA) in 18.3%, vascular plug (AGA) in 3.4%, and a combination of coil/ vascular plug/amplatzer in 3.4%. Postoperative complications were reported in 4 patients as external iliac artery thrombosis, transient PSVT, ST-T wave changes and mild pericardial effusion that were all managed successfully with no adverse sequels. No coronary artery injury, device dislocation, dissection, ischemia or coronary dilatation occurred, and there was no death. As larger fistulas were treated by a retrograde approach through the right side of the heart, there was significant correlation between residual shunts and the mode of closure approach; the majority of the residual shunts occurred in patients in the retrograde approach group.

CONCLUSIONS

Trans-catheter approach for treating CAFs leads to appropriate long-term outcome with minimal potential side effects.

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.

Coronary arterial fistulas

A coronary arterial fistula is a connection between one or more of the coronary arteries and a cardiac chamber or great vessel. This is a rare defect and usually occurs in isolation. Its exact incidence is unknown. The majority of these fistulas are congenital in origin although they may occasionally be detected after cardiac surgery. They do not usually cause symptoms or complications in the first two decades, especially when small. After this age, the frequency of both symptoms and complications increases. Complications include 'steal' from the adjacent myocardium, thrombosis and embolism, cardiac failure, atrial fibrillation, rupture, endocarditis/endarteritis and arrhythmias. Thrombosis within the fistula is rare but may cause acute myocardial infarction, paroxysmal atrial fibrillation and ventricular arrhythmias. Spontaneous rupture of the aneurysmal fistula causing haemopericardium has also been reported. The main differential diagnosis is patent arterial duct, although other congenital arteriovenous shunts need to be excluded. Whilst two-dimensional echocardiography helps to differentiate between the different shunts, coronary angiography is the main diagnostic tool for the delineation of the anatomy. Surgery was the traditional method of treatment but nowadays catheter closure is recommended using a variety of closure devices, such as coils, or other devices. With the catheter technique, the results are excellent with infrequent complications.

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.

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.

[Left to right shunt for congenital coronary arterio-venous fistulas]

Congenital coronary artery fistulas are rare malformations that may evolve to pulmonary hypertension, heart failure and myocardial ischemia, although some may close spontaneously. Complications such as endocarditis, rupture, aneurysm or thrombosis may also be observed. Most patients are asymptomatic and the fistulas are usually detected by doppler echocardiography and angiography. We report the case of an asymptomatic 10-year-old male who was submitted because he of a heart murmur, and three coronary fistulas were diagnosed. Two originated in the left coronary artery draining into the right ventricle and the other origin was in the right coronary artery draining into the pulmonary artery trunk.

Isolated congenital coronary arteriovenous fistula

During the last eight years a total of nine cases of isolated congenital coronary arteriovenous fistula (CAVF) have been diagnosed at our centre. Age of these patients ranged from 11 days to 22 years (mean 6.4 +/- 4.2 years). There were seven male and two female patients. Right and left coronary arteries were the sites of origin in seven and three cases respectively. One patient had two fistulae, one each originating from right coronary artery and obtuse marginal artery. The drainage sites were right ventricle in seven cases and right atrium in two. The pulmonary artery pressure was normal in eight cases and elevated in one case. The pulmonary artery to systemic flow ratio ranged from 1.1:1-2.4:1 in all except the 11 day-old-baby in whom it was 4:1. Pulmonary vascular resistance (PVRI) was below 3.5 in all cases (range 1.0-3.5 units). Surgical ligation of fistula was done in four cases and two patients underwent coil embolisation of fistula. Follow-up is available in five out of eight patients including three cases in whom CAVF was closed. Two other young patients are being followed-up conservatively and all the patients are asymptomatic. CAVF can present at any age; majority of the cases have small left to right shunts and more commonly CAVF arise from right coronary artery. Surgical ligation of fistula is safe in older patients, non-surgical embolisation using coils may be an alternative to surgery in selected cases.

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

A 9-year-old patient with a large coronary arteriovenous fistula (circumflex-right atrium) underwent successful complete percutaneous closure, using the new Amplatzer Duct Occluder (ADO) inserted via a 6 Fr sheath.