Transcatheter Closure of Coronary Artery Fistulae: Considerations and Approaches Based on Fistula Origin

Transcatheter Closure of Large Coronary-Cameral Fistulas Using the Patent Ductus Arteriosus Occluder or Amplatzer Vascular Plugs

Transcatheter closure (TCC) has emerged as the first-line treatment for coronary artery fistulas. However, limited data exist regarding the long-term outcomes and technical aspects of this procedure. We aimed to report the long-term outcomes and technical aspects of TCC of large coronary-cameral fistulas (CCFs).All patients with large CCFs who underwent attempted TCC using the patent ductus arteriosus (PDA) occluder or Amplatzer vascular plug (AVP), from June 2002 to December 2017, were retrospectively reviewed. A total of 23 patients with large CCFs underwent attempted TCC using the PDA occluder or AVP. Most CCFs originated from the right coronary artery and drained predominantly into the right heart chamber. Procedural success was achieved in 21 (91.3%) patients. Devices were deployed using the arteriovenous loop in 15, transarterial approach in 4, and arterio-artery loop approach in 2 patients. Procedural complications included coronary spasm in one and side branch occlusion in one patient. Among these 21 patients with successful device implantation, follow-up angiograms or computed tomography angiograms were obtained in 14 (66.7%) patients at a median of 11.0 (range, 9.8-16.3) months. Late complications included thrombosis of residual fistula segment without myocardial infarction (MI) in one, coronary thrombosis resulting in MI in one, and recanalization necessitating re-intervention in one patient. No death and device embolization occurred.TCC of large CCFs using the PDA occluder or AVP is an effective therapy in anatomically suitable candidates, with favorable long-term outcomes. Given that potentially hazardous complications may occur late after the procedure, long-term periodic evaluation is mandatory.

Congenital coronary artery fistula: Presentation in the neonatal period and transcatheter closure

BACKGROUND

Congenital coronary artery fistula is a rare coronary anomaly. Most commonly, such fistulae drain into the right side of the heart or the pulmonary artery. Children with coronary artery fistulae are generally asymptomatic, although they may have left ventricular enlargement in the setting of a moderate sized left to right shunt. Symptoms of congestive heart failure or ischemia are very rare in neonatal period, and suggest the presence of a very large shunt and/or coronary steal.

METHODS

Single center retrospective review of transcatheter intervention on coronary artery fistulae presenting with symptoms in the neonatal period from January 2000 to March 2018. Patients with associated congenital heart diseases (except atrial septal defect) were excluded. Patient records, catheterization data, angiograms and noninvasive imaging were reviewed.

RESULTS

Two patients underwent transcatheter intervention for symptomatic coronary artery fistula in the first few weeks of life. The first patient had multiple right and left coronary artery to right ventricle fistulae and presented with severe biventricular systolic dysfunction. Transcatheter closure of the fistulae was performed using multiple Gianturco coils. The second patient had a large left main coronary artery to left ventricle fistula (with left anterior descending and circumflex coronary artery atresia) presenting with symptoms of ischemia. This large fistula was closed using one Amplatzer Vascular Plug type-II and two Micro-Vascular Plugs. Both patients had improvement in symptoms post intervention and are doing well at the last follow up at 12 years and 7 months respectively.

CONCLUSIONS

We hereby describe the rare presentation of symptomatic coronary artery fistulae in the neonatal period and their successful transcatheter management. This is also the first description of left anterior descending and circumflex coronary artery atresia in the setting of a large left main coronary artery to left ventricle fistula.

Coronary-cameral fistulas: indications and methods for closure

Coronary-cameral fistulas (CCF) are anomalous connections between one or more coronary arteries and a cardiac chamber, most commonly the right ventricle or right atrium. The major indications for closure are: significant left to right shunt, myocardial ischaemia, prevention of endoarteritis or rupture. Nowadays, the first option for treatment is transcatheter closure. According to the morphology of the fistulas the most appropriate occluder device should be selected: coils (e.g., Gianturco coils, controlled-release coils, PFM coils), vascular plugs or a patent ductus arteriosus (PDA) device or muscular ventricular septal defect (VSD) device. The way to deploy the occluders could be direct arterial or venous through an arteriovenous loop, according to the anatomy of the fistulas assessed by multiple angiograms in different projections. A test occlusion of the fistula with balloon catheter and simultaneous coronary angiogram is recommended for choosing the proper device type and size and the best position for deployment to achieve complete occlusion of the fistula without compromising the flow in coronary side branches.

Closure of coronary artery fistula in childhood: treatment techniques and long-term follow-up

INTRODUCTION

Coronary artery fistula (CAF) is a rare congenital anomalous connection between the coronary arteries (CA) and a cardiac chamber or great vessel. Treatment options of symptomatic CAF consist of transcatheter or surgical closure.

METHODS

Retrospective analysis of all patients with CAF diagnosed between 1993 and 2014 concerning treatment approaches and follow-up after closure.

RESULTS

In a cohort of more than 25000 patients, 194 (<0.01 %) were diagnosed to have CAF. Median age at diagnosis was 6 months (0 day-18 years). Treatment was indicated in ten patients (5.2 %). Six patients (60 %) were treated by catheter interventional approach using Coils (three patients), Amplatzer Vascular Plugs (two patients) and Amplatzer Duct Occluder (one patient). One of these patients showed a significant residual shunt through the fistula 5 days after interventional closure, necessitating surgical removal of the device and closure of CAF. At a median follow-up of 7 (range 2-12) years, the remaining five patients showed successfully closed CAF without causing thrombosis of the CA. Control angiography in three patients showed persistent dilated CA. Surgical closure of CAF was performed in four (40 %) patients; in two as an isolated procedure and in the remaining two as a part of another congenital cardiac corrective procedure.

CONCLUSIONS

CAF in paediatric cardiology patients is a very rare finding. Intervention in childhood is rarely needed; nevertheless, it is known that small fistulas may become relevant in adulthood. Transcatheter closure techniques are effective and are considered the treatment of choice, especially in isolated CAF.