Transcatheter embolization of congenital coronary arterial fistulas in adults

Transcatheter closure of coronary artery fistulae: initial human experience with the Amplatzer Duct Occluder II

OBJECTIVES

To evaluate the efficacy and safety of the new device Amplatzer Duct Occluder II (ADO II) for the closure of coronary artery fistulae (CAF) with coronary anomaly.

BACKGROUND

Transcatheter device closure is an alternative treatment for selective patients with CAF. The currently available reports regarding the closure of CAF with the ADO II are limited.

METHODS

From April 1, 2011 to July 15, 2012, 5 patients (3 males and 2 females) aged from 3 years to 27 years old (median age 5 years old) underwent CAF closure with the ADO II. The immediate and short-term outcomes were evaluated.

RESULTS

ADO II was deployed via the femoral vein (2 cases), femoral artery (1 case), brachial artery (1 case), and radial artery (1 case). There were no complications during all the procedures. The median fluoroscopy and procedural times were 20 and 39 minutes, respectively. Immediate trivial and mild residual shunt was present in one patient, respectively, but disappeared 24 hours after the procedure, and there was no recanalization at a median follow-up of 6 months.

CONCLUSIONS

The new device ADO II was safely deployed with complete resolution of CAF shunt with tortuous coronary artery to the drainage. The reduced sheath sizes and softer shape of this device allow for venous or arterial approach. The ADO II might be a preferable alternative device for closure of small-tortuous CAFs.

Percutaneous closure of congenital coronary artery fistulae: results and angiographic follow-up

OBJECTIVES

This study sought to assess clinical and angiographic outcomes in a series of 29 patients who underwent transcatheter closure of coronary artery fistulae (CAF).

BACKGROUND

Transcatheter closure of CAF has become an alternative to surgical closure, but the reported experience is relatively limited.

METHODS

Medical records of all patients with CAF who underwent transcatheter closure at the Mayo Clinic, Rochester, Minnesota, between 1997 and 2010, were reviewed. Patients with other complex cardiac lesions and those requiring surgery were excluded.

RESULTS

Twenty-nine patients with CAF underwent 36 transcatheter closure procedures. The most were women (55%), and the median age at the time of transcatheter closure was 49 years. Twenty-three patients had a single CAF. The most common presenting symptom was chest pain (52%). Thirty devices were deployed antegrade into 1 or more arterial feeders, 3 using an arteriovenous wire loop and 3 retrograde at the fistulous connection. Successful closure occurred immediately in all patients with no residual flow in 89% and with trivial flow in 11%. Four complications occurred including 2 device migrations, 1 coronary spasm, and 1 coronary thrombosis. A follow-up angiogram was obtained in 18 (62%) patients with a median time to follow-up angiography of 1.5 years. Ten patients (56%) of the 18 patients with follow-up angiography had no recanalization of embolized vessel; 4 patients (22%) had trivial recanalization, and 4 patients (22%) had large recanalization. A repeat closure procedure was performed in all 4 patients of the latter.

CONCLUSIONS

Transcatheter closure of CAF is feasible and should be considered in carefully selected patients. Recanalization of the treated coronary fistulae can occur, so follow-up angiography or other imaging modality should be performed in these patients.

Transcatheter closure of congenital coronary arterial fistulas in adults

OBJECTIVES

We have described our experience with transcatheter occlusion of congenital coronary arterial fistulas in adults.

METHODS

Six symptomatic patients, mean aged 41+/-12 years (four men, two women) underwent transcatheter occlusion of fistulas. All had chest pain or dyspnea on exertion. Four of the patients had single fistula. Two of the patients had multiple fistulas. The fistulas originated from the left anterior descending coronary artery in four patients, and from the circumflex artery in two. They all drained into the pulmonary trunk. Graft stenting was used in two patients who had multiple fistulas, and coils in four who had a single fistula. The coils were implanted through a microcatheter, which was passed through a JL 4 8F guiding catheter.

RESULTS

Coils were used to completely occlude fistulas. Two 3.0x20 mm coronary graft stents were deployed in the coronary arteries to occlude the fistulas. The procedures were uncomplicated. At follow up, all patients underwent coronary angiography, and one of the patients with coil embolization and one of the patients with graft stenting had small residual flow. Patient's chest pain or dyspneas have resolved after the procedure.

CONCLUSION

Transcatheter closure in adults of congenital coronary fistulas with graft stents and coils are safe and effective, and can be regarded as an acceptable alternative to surgery.

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.

A Complicated Percutaneous Coil Embolisation of a Large Coronary Artery Fistula

A coronary artery fistula is a rare cause of cardiac symptoms or signs in an adult. We report here the successful percutaneous treatment of a large fistula in an adult who had suffered an acute myocardial infarction peri-operatively due to a steal phenomenon. Due to the fistula size, a specially constructed occlusion device was utilised for effective treatment.

Management of coronary artery fistulae. Patient selection and results of transcatheter closure

OBJECTIVES

We report short-term findings in 33 patients after transcatheter closure (TCC) of coronary artery fistulae (CAF) and compare our results with those reported in the recent transcatheter and surgical literature.

BACKGROUND

Transcatheter closure of CAF has been advocated as a minimally invasive alternative to surgery.

METHODS

We reviewed all patients presenting with significant CAF between January 1988 and August 2000. Those with additional complex cardiac disease requiring surgical management were excluded.

RESULTS

Of 39 patients considered for TCC, occlusion devices were placed in 33 patients (85%) at 35 procedures and included coils in 28, umbrella devices in 6 and a Grifka vascular occlusion device in 1. Post-deployment angiograms demonstrated complete occlusion in 19, trace in 11, or small residual flow in 5. Follow-up echocardiograms (median, 2.8 years) in 27 patients showed no flow in 22 or small residual flow in 5. Of the 6 patients without follow-up imaging, immediate post-deployment angiograms showed complete occlusion in 5 or small residual flow in 1. Thus, complete occlusion was accomplished in 27 patients (82%). Early complications included transient ST-T wave changes in 5, transient arrhythmias in 4 and single instances of distal coronary artery spasm, fistula dissection and unretrieved coil embolization. There were no deaths or long-term morbidity. Device placement was not attempted in 6 patients (15%), because of multiple fistula drainage sites in 4, extreme vessel tortuosity in 1 and an intracardiac hemangioma in 1.

CONCLUSIONS

A comparison of our results with those in the recent transcatheter and surgical literature shows similar early effectiveness, morbidity and mortality. From data available, TCC of CAF is an acceptable alternative to surgery in most patients.

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.

A case of coronary artery fistula draining into the pericardium causing hematoma

A 28-yr old female patient admitted to our clinic because of dyspnea and chest pain. Her transesophageal echocardiography demonstrated a huge mass on the anterolateral wall of the left ventricle causing dysfunction of the myocardium. Coronary angiography demonstrated left anterior descending artery fistula draining into the pericardial cystic mass. Hydatic cyst was suspected and ELISA and hemagglutinin tests were both negative for Echinococcus granulosus. Magnetic resonance image of the heart showed a mass thought to be a hematoma inside the cyst. She underwent surgery. The cystic lesion with a pure hematoma inside, was excised, and the fistula between left anterior descending artery and the mass was ligated without any complications. To our knowledge, this is the first case of a pericardial hematoma due to a coronary artery fistula, in the English literature.