From the Department of Cardiac and Vascular Interventional services, Lenox Hill Heart and Vascular Institute of New York. Disclosure: Dr. Carlos Ruiz is a consultant to AGA Medical Corporation. Neither Dr. Schneider nor Dr. Jain have conflicts related to the content herein. Manuscript submitted October 30, 2008, provisional acceptance given December 8, 2008, and final version accepted December 11, 2008. Address for correspondence: Laurence M. Schneider, MBBCh, FRACP, Lenox Hill Heart and Vascular Institute of New York, Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute of New York, 130 East 77th Street, 9th Floor Blackhall, New York, NY 10025. E-mail: email@example.com
J INVASIVE CARDIOL 2009;21:E55-E56
Percutaneous closure of coronary fistulae with different devices1,2 is well described using both retrograde and antegrade approaches.3 In the presence of congestive heart failure, significant left-to-right shunting, or arrhythmias, elective closure is accepted.4 This case demonstrates a unique method of ensuring continuous access through the fistula during deployment of a closure device. Case Report. A 67-year-old female presented to the emergency room of another hospital with right-sided hemiparesis status post cerebrovascular accident. She had poorly controlled atrial fibrillation on coumadin with symptoms of moderate-to-severe dyspnea. A transthoracic echocardiogram revealed a large, tubular aneurysmal structure with high-velocity flow from the left to the right. Coronary angiography was performed revealing a coronary fistula from the proximal left anterior descending artery (LAD) to the right atrium (RA) (Figure 1A), with oximetry measuring a systemic-to-pulmonary shunt of > 1.5:1. This was considered severe enough to necessitate treatment, and she was referred to our institution for elective closure of the fistula. We performed a computed tomographic angiogram (CTA) prior to sending her to the catheterization laboratory (Figures 1B and C). The fistula was wired antegradely with microcatheter backup support and captured by a snare in the inferior vena cava, creating an arteriovenous loop (Figure 2A). A sheath was advanced retrogradely into the mid-fistula via the RA. A 10 mm vascular plug (AGA Medical Corp., Golden Valley, Minnesota) was retrogradely advanced into the mid-fistula, with the wire still in situ and successfully deployed (Figure 2B). Angiography revealed incomplete closure with the vascular plug, but due to retention of the wire’s position, we were able to easily advance an 8 mm Amplatzer ventricular septal defect closure device (AGA Medical) and successfully deploy it adjacent to the vascular plug. No flow through the fistula was thereafter immediately demonstrated (Figure 3A). She was kept on intravenous heparin until the international normalized ratio (INR) was > 2, the coumadin having been resumed that evening. A CTA was performed the following day, showing no contrast flow through the fistula and both devices were seen to be in a good position (Figures 3B and C). A wire-in-situ technique during Amplatzer device deployment has not previously been described with coronary fistula percutaneous closure. This technique provides continuous access and the ability to try again with multiple devices through the same access site when procedural success or accurate device positioning is not ensured. The same technique can be applied to difficult atrial septal defect, ventricular septal defect or patent ductus arteriosus percutaneous closure. Figure 3 Legend: (A) Angiogram showing complete occlusion of fistula with a ventricular septal defect occluder and vascular plug (arrows). (B) Three-dimensional computed tomographic image post processing using the volume rendering technique showing device position(s) (arrows). (C) Curved multiplanar reconstruction of the fistula with arrows showing device’s completely occluding contrast flow. Ao = ascending aorta; PA = pulmonary artery; LM = left main coronary artery; SVC = superior vena cava, LA = left atrium.
1. Sadiq M, Wilkinson JL, Qureshi SA. Successful occlusion of a coronary arteriovenous fistula using an Amplatzer duct occluder. Cardiol Young 2001;11:84–87. 2. Ascoop A, Budts W. Percutaneous closure of a congenital coronary artery fistula complicated by an acute myocardial infarction. Acta Cardiol 2004;59:67–69. 3. Collins N, Mehta R, Benson L, Horlick E. Percutaneous coronary artery fistula closure in adults: Technical and procedural aspect. Catheter Cardiovasc Interv 2007;69:872–880. 4. Pedrs CA, Pihkala J, Nykanen DG, et al. Antegrade transcatheter closure of coronary artery fistulae using vascular occlusion devices. Heart 2000;83:94–96.