Fistulas In Adults Research Articles

The effects of transcatheter closure of coronary-pulmonary arterial fistulas in adults

ObjectiveCongenital coronary artery fistula (CAF) is an extremely rare congenital anomaly of the coronary artery. We report our experience with Tran catheter occlusion of coronary-pulmonary artery fistula.MethodsCAFs were identified incidentally...

Diagnostic and therapeutic approach of congenital solitary coronary artery fistulas in adults: Dutch case series and review of literature

Coronary artery fistulas (CAFs) are infrequent anomalies, coincidentally detected during coronary angiography (CAG). To elucidate the currently used diagnostic imaging modalities and applied therapeutic approaches. Five Dutch patients were found to have CAFs. A total of 170 reviewed subjects were subdivided into two comparable groups of 85 each, treated with either percutaneous 'therapeutic' embolisation (PTE group) or surgical ligation (SL group). In our series, the fistulas were visualised with several diagnostic imaging tests using echocardiography, multidetector computed tomography, and CAG. Four fistulas were unilateral and one was bilateral; five originated from the left and one originated from the right coronary artery. Among the reviewed subjects, high success rates were found in both treatment groups (SL: 97% and PTE: 93%). Associated congenital or acquired cardiovascular disorders were frequently present in the SL group (23%). Bilateral fistulas were present in 11% of the SL group versus 1% of the PTE group. The fistula was ligated surgically in one and abolished percutaneously in another. Medical treatment including metoprolol was conducted in two, and watchful waiting follow-up was performed in one. Several diagnostic imaging techniques are available for assessment of the anatomical and functional characteristics of CAFs.

Current characteristics of congenital coronary artery fistulas in adults: A decade of global experience

To describe the characteristics of coronary artery fistulas (CAFs) in adults, including donor vessels and whether termination was cameral or vascular. A PubMed search was performed for articles between 2000 and 2010 to describe the current characteristics of congenital CAFs in adults. A group of 304 adults was collected. Clinical data, presentations, diagnostic modalities, angiographic fistula findings and treatment strategies were gathered and analyzed. With regard to CAF origin, the subjects were tabulated into unilateral, bilateral or multilateral fistulas and compared. The group was stratified into two major subsets according to the mode of termination; coronary-cameral fistulas (CCFs) and coronary-vascular fistulas (CVFs). A comparison was made between the two subsets. Fistula-related major complications [aneurysm formation, infective endocarditis (IE), myocardial infarction (MI), rupture, pericardial effusion (PE) and tamponade] were described. Coronary artery-ventricular multiple micro-fistulas and acquired CAFs were excluded as well as anomalous origin of the coronary arteries from the pulmonary artery (PA). A total of 304 adult subjects (47% male) with congenital CAFs were included. The mean age was 51.4 years (range, 18-86 years), with 20% older than 65 years of age. Dyspnea (31%), chest pain (23%) and angina pectoris (21%) were the prevalent clinical presentations. Continuous cardiac murmur was heard in 82% of the subjects. Of the applied diagnostic modalities, chest X-ray showed an abnormal shadow in 4% of the subjects. The cornerstone in establishing the diagnosis was echocardiography (68%), and conventional contrast coronary angiography (97%). However, multi-slice detector computed tomography was performed in 16%. The unilateral fistula originated from the left in 69% and from the right coronary artery in 31% of the subjects. Most patients (80%) had unilateral fistulas, 18% presented with bilateral fistulas and 2% with multilateral fistulas. Termination into the PA was reported in unilateral (44%), bilateral (73%) and multilateral (75%) fistulas. Fistulas with multiple origins (bilateral and multilateral) terminated more frequently into the PA (29%) than into other sites (10.6%) (P = 0.000). Aneurysmal formation was found in 14% of all subjects. Spontaneous rupture, PE and tamponade were reported in 2% of all subjects. In CCFs, the mean age was 46.2 years whereas in CVFs mean age was 55.6 years (P = 0.003). IE (4%) was exclusively associated with CCFs, while MI (2%) was only found in subjects with CVFs. Surgical ligation was frequently chosen for unilateral (57%), bilateral (51%) and multilateral fistulas (66%), but percutaneous therapeutic embolization (PTE) was increasingly reported (23%, 17% and 17%, respectively). Congenital CAFs are currently detected in elderly patients. Bilateral fistulas are more frequently reported and PTE is more frequently applied as a therapeutic strategy in adults.

Benign Bronchoesophageal Fistula in Adults: Endoscopic Closure as Primary Treatment

Benign bronchoesophageal fistula (BEF) is a rare condition that is usually treated surgically; however, less invasive endoscopy procedures have been attempted to overcome the disadvantages of surgery. The aim of this study was thus to determine the results of endoscopic management as a primary treatment in patients with BEF. We retrospectively analyzed data from 368 patients with BEF who were treated at a tertiary care, academic medical center between January 2000 and August 2009. Benign causes were found for only 18 of the 368 patients. Of these, seven were treated endoscopically and the others by surgery or other methods. The first endoscopy procedures failed in all seven patients, with second trials of endoscopy performed in four patients at a median of 8 days (range, 3 to 11 days) after the first procedure. The second endoscopic procedure was successful in two out of four patients; one patient showed no recurrence of the fistula, whereas the second patient experienced a recurrence after 24 months. All patients underwent successful surgical procedures after the failure of endoscopic treatment, with no further recurrences. Although we observed a low rate of success for primary endoscopic treatment of benign BEF, the invasive nature of surgery suggests the need for a prospective study with a large number of patients to evaluate the efficacy of less invasive procedures such as endoscopic treatment.

Complex coronary artery fistulas in adults: evaluation with multidetector computed tomography

Coronary artery fistulas (CAFs) are rare congenital or acquired abnormalities that have anomalous terminations of the coronary arteries. Although many patients with CAFs are asymptomatic, they can display various clinical features associated with ischemic heart disease or heart failure. Making an early diagnosis is important for the proper management and prevention of late symptoms and complications. Conventional coronary angiography and cardiac CT have been commonly performed to diagnose CAFs, but multi-detector computed tomography (MDCT) is now being widely applied for diagnosing cardiovascular anomalies, and the number of incidentally detected CAFs on MDCT has been increasing. Therefore, we have to be familiar with the image findings of CAFs, and especially the image findings of MDCT for making the correct diagnosis of CAFs. In this article, we illustrate the MDCT findings of various types of CAFs in adults and we review the pathophysiology and clinical features of CAFs.

Treatment of post-prostatectomy rectourethral fistula with fibrin sealant (Quixil™) injection: a novel application

Rectourethral fistulas in adults is a rare but potentially devastating postoperative condition requiring complex and demanding surgery. Fibrin glue treatment has been used with some success in anal and rectovaginal fistulas, and in the case we present here this indication has been extended to a postoperative rectourethral fistula following radical prostatectomy. For the first time, to our knowledge, a fibrin sealant (Quixil) was injected into the fistula tract, and a rectal mucosal flap was used to close the internal opening. The fistula healed in few weeks, and the patient is symptom free after 1year of follow-up.

A case report of congenital bronchobiliary fistula in adults

A case report of congenital bronchobiliary fistula in adults

Endoscopic Approach to Tracheoesophageal Fistulas in Adults

Tracheoesophageal fistulas (TEF) in adults are primarily of malignant etiology with esophageal and lung cancers being the most common. Most cases of benign TEF have iatrogenic causes. Historically, the recommended treatment of TEF was surgical. Although this is still the case for benign TEF, endoscopic stent insertion is currently the recommended approach for malignant TEF, as well as benign TEF when the surgical approach must be deferred. Since the mid-1990s self-expanding metal stents (SEMS) have replaced rigid plastic prosthesis as the stent of first choice. SEMS close 89% of TEFs, although the rate of recurrence has been reported as high as 35%. Some patients require stents in the trachea as well as the esophagus to achieve complete closure of the TEF. In others, tracheal stents alone are sufficient. The recently introduced self-expanding plastic stents (SEPS) are more readily removed than most SEMS and have a role in treating benign TEF. SEPS role in malignant TEF is being defined. Stent selection and placement technique are reviewed for various clinical scenarios.

Transcatheter closure of congenital coronary arterial fistulas in adults

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

Female Gender and the Risk of Rupture of Congenital Aneurysmal Fistula in Adults

To delineate the risk factors for rupture of congenital aneurysmal fistulas in adult patients. We conducted a literature search of the Medline database using Pubmed search interface to identify reports dealing with rupture of congenital aneurysmal fistulas in an adult population. The search included the English and non-English languages between 1963 and 2005. Fourteen adult patients (12 females) with serious and life-threatening complications secondary to aneurysmal fistulas were reported. Mean age was 62.9 years. The ethnic origins of these 14 patients were 9 Asian and 5 Caucasian. Most patients have had no other cardiac malformations. Five patients had a history of hypertension. One patient was asymptomatic. In 13 symptomatic patients, the clinical presentation was cardiac tamponade, pericardial effusion, syncope, heart failure, chest pain, dyspnea, fatigue, distal thromboembolic events with infarction, shock, and/or sudden death. Aneurysmal fistulas were identified in 10 patients; of these 6 were of the saccular type. Rupture occurred in 9 patients (8 females and 1 male). Eleven patients were treated surgically with 1 late death. Two male subjects experienced sudden unexpected cardiac death. Rupture of congenital aneurysmal fistulas occurred more often in females. Identified risk factors for rupture, hemopericardium, tamponade, and death were among others saccular aneurysm, Asian ethnic race, origin of the aneurysmal fistulas from the left coronary artery and a history of hypertension may play a role. In this article, we present a literature review of congenital aneurysmal fistulas associated with or without rupture and a case report of a woman with unruptured aneurysmal fistula.

Congenital coronary artery fistulas in adults: concomitant pathologies and treatment

Coronary artery fistula is a rare congenital malformation. Complications such as intracardiac shunts, endocarditis, myocardial infarction, aneurysm and sudden death can be observed. The purpose of this article is to present our experience with concomitant cardiac pathologies and discuss various therapeutic approaches including surgical and percutaneous intervention. During 18,272 diagnostic cardiac catheterizations, coronary artery fistulas were identified incidentally in 10 patients (0.05%). There were 3 female and 7 male patients. The patients' ages ranged from 42 to 76 years. All patients with coronary artery fistula were preoperatively in New York Heart Association functional class and Canadian Cardiovascular Society class II or III. In addition to coronary artery fistula, coronary artery disease was detected in 4 patients (40%), a ventricular septal defect and an aneurysm of the sinuses of Valsalvae with aortic regurgitation in one patient (10%) and an anomalous origin of the LAD from the pulmonary trunk in one patient (10%) during cardiac catheterization. Four (40%) of the total of 10 patients had only coronary artery fistula. Surgical closure of the coronary artery fistula was performed in 7 patients (70%). An interventional fistula closure with a coil device was confirmed by cardiac catheterization in another 3 patients (30%). One patient of the latter group showed a small residual shunt from the LAD to the pulmonary trunk. No death or long-term morbidities could be observed. Coronary artery fistulas are incidentally diagnosed during coronary artery angiographies in adults and should be closed to prevent complications.

Feasibility of Cardiovascular Magnetic Resonance of Angiographically Diagnosed Congenital Solitary Coronary Artery Fistulas in Adults

To evaluate the use of cardiovascular magnetic resonance (CMR) to visualize angiographically-detected congenital coronary artery fistulas in adults. CMR techniques were used to study 13 patients, recruited from the Dutch Registry, with previously angiographically diagnosed fistulas. Coronary fistulas were detected in 10 of 13 (77%) patients by CMR and, retrospectively, in two (92%) more. In 93% of these, it was possible to determine the origin and the outflow site of the fistulas. Cardiovascular magnetic resonance allowed demonstration of dilatation of the fistula-related coronary artery in all cases. Tortuosity of fistulas was detected in all visualized patients. Uni-or bilaterality of fistulas as seen on CAG was proven on CMR in all patients. Flow measurement could be performed in 8 patients. A fairly good correlation (r = 0.72) was found between angiographic (mean 6.2 mm, range 1-16) and cardiovascular magnetic resonance (mean 6.3 mm, range 3-15) measured fistulous diameters. Cardiovascular magnetic resonance of congenital fistulas with clinical significant shunting is feasible and can provide additional physiological data complementary to the findings of conventional coronary angiography.

Successful percutaneous closure of multiple coronary artery fistulas with coils embolization in two adults

Fistulas between coronary arteries and cardiac cavities or other vascular structures are uncommon findings usually detected early in life. We describe two cases of late transcatheter occlusion of a double coronary artery fistula in adults complaining of incremental dyspnoea.

Acquired tracheo-oesophageal fistula in adults

Acquired tracheo-oesophageal fistula in adults

Two Cases of Congenital Esophagobronchial Fistula in Adults

成人発症の先天性食道気管支瘻の2例を報告する。症例1は65歳，女性。慢性咳嗽の既往歴あり。検診でのバリウム食道造影検査で瘻を指摘されて当院を受診した。胸部CTでは中部食道から右のB6気管支に及ぶ食道気管支瘻を認めた。気管支鏡検査では，食道チューブから入れた色素剤の右B6からの流出が観察された。瘻の切除術が施行された。病理学的に，瘻は扁平上皮で被われ，固有筋層をもち，先天性食道気管支瘻と診断された。 症例2は57歳，男性。発熱と喀血で受診した。以前の検診での食道造影で食道から右下葉気管支への瘻を指摘されていた。胸部CTでも食道気管瘻が認められた。食道内視鏡検査で憩室と瘻の入口部が観察された。食道と右B6気管支の瘻との交通は，症例1と同様に気管支鏡と色素注入で確認した。瘻の切除と右下葉切除術が施行された。瘻の遺残組織周囲には炎症所見が認められた。病歴からは，瘻からの食物の誤嚥が肺膿瘍を引き起こしたと推測された。 食道気管支瘻の早期診断には胸部CTが重要な役割を果たす可能性がある。

Dutch survey of congenital coronary artery fistulas in adults: Coronary artery-left ventricular multiple micro-fistulas: Multi-center observational survey in the Netherlands

Background Congenital coronary artery-left ventricular multiple micro-fistulas (CA-LVMMFs) in adults are rare anomalies. They may cause angina pectoris and myocardial infarction in association with normal coronary arteries. Methods and results From the medical databases of a Dutch Survey of coronary artery fistulas in adult cardiology population (30,829 patients), we identified 20 patients with CA-LVMMFs out of 71 fistula-subjects between 1996 and 2003. Clinical files and individual coronary angiograms were reviewed and analysed. There were 13 females and 7 males with a mean age of 67.3 years (range 49–82). The main presenting symptoms were angina pectoris and dyspnea in 70% of the patients. The ECG showed pathologic changes in 75%. Exercise tolerance test and 201-thallium stress scintigraphy were positive for myocardial ischemia in 29% and 50%, respectively of the tested patients. In the absence of significant atherosclerotic coronary artery disease, ipsilateral to the fistulas, myocardial infarction was documented in 15% of the patients. Chest X-ray revealed cardiomegaly in 38% of the patients. Congestive heart failure was documented in 10% of the patients. Uni-, bi- and multilateral fistulas were present in 50%, 45% and 5%, respectively. The origin was the LCA in 71% and the RCA in 29% of the fistulas. The majority (97%) originated from the mid or distal segments of the coronary vessels. Among those patients, the coronary arterial tree had single, dual, and triple vessel disease in 25%, 15% and 5%, respectively. Angiographic anatomy precludes surgical intervention; they were all followed by conservative medical management. Conclusions Coronary artery-left ventricular multiple micro-fistulas are found more often in female patients. Furthermore, they originated from the distal segment of the coronary arteries. Coronary artery-left ventricular multiple micro-fistulas, in the presence of normal coronary arterial tree, may often lead to angina pectoris and coronary insufficiency.

Dutch survey of coronary artery fistulas in adults: Congenital solitary fistulas

Aims Congenital coronary artery fistulas are frequently identified in adult and pediatric populations and they have been associated with various clinical and morphological features. The purpose of this study was to define the clinical and coronary angiographic morphological characteristics of adult patients with congenital solitary CAFs in the Dutch Registry. Methods and results Fifty-one patients with angiographically documented CAFs were reviewed for clinical evaluation, used non-invasive and invasive diagnostic tools and treatment modalities. Unilateral CAFs were predominant (80%) and 84% of the patients were symptomatic. The most common presenting symptom was angina pectoris (57%). Angina pectoris was present in a quarter of the patients in the absence of coronary artery disease (CAD). Significant CAD was present in 49% of the patients. Twenty-nine percent of the CAFs showed aneurysmal formation, underlying their potential hazard of rupture. Myocardial infarction occurred in 18% of the patients. In 27% of CAFs multiplicity of the origin was found and nearly all fistulas were tortuous (97%). Treatment modalities were conservative medical in 70%, percutaneous transluminal embolisation in 5% and surgical ligation in 25% of the cases. Multiple micro-fistulas from the coronary arteries to the left ventricle were excluded from the study. Conclusion In this national survey series, congenital solitary CAFs can be presented with typical angina pectoris in the absence of obstructive CAD. Fistula-related coronary artery was infrequently involved in the development of ipsilateral myocardial infarction. Tortuousity and multiplicity of the CAFs may determine, for the individual patient, the choice of the currently available treatment modalities.

Percutaneous Occlusion With Coils of Coronary Artery Fistulas in Adults

Coronary artery fistulas are one of the most common congenital anomalies of the coronary arteries. Most fistulas are small and of no clinical significance, although larger or multiple fistulas can be symptomatic and produce complications. Early percutaneous occlusion is now always recommended, and surgical closure is restricted to use for multiple or large fistulas. Here we report four cases of coronary fistula draining from the coronary arteries to the pulmonary vascular bed, which were treated with percutaneous occlusion by coils.

Congenital coronary artery fistulas in adults: surgical treatment and outcome

Background: Congenital coronary artery fistulas, a subgroup of anomalies of the coronary arteries, are an extremly rare cardiac defect. Most patients are asymptomatic, and if symptoms are presented, they depend on the underlying anatomy. Knowledge of those fistulas is important for prognosis and management. Methods: Thirteen adult patients with congenital coronary fistulas (8 male, 5 female) were operated in our department during the last decade (1990–1999). Mean age was 61.5±10.8 years. Diagnosis was made by coronary angiography, and 15 congenital coronary artery fistulas were found. Results: All patients were symptomatic with clinical symptoms depending on the associated cardiac disorder. Coronary artery fistulas originated from the proximal left descending artery ( n=10), left main stem ( n=3), circumflex artery ( n=1), right coronary artery ( n=1), and drained into the main pulmonary artery ( n=14) and left ventricle ( n=1). Nine fistulas (60%) were interrupted on the outside of the heart, and six fistulas (40%) were closed through the opened pulmonary artery. There was no surgical death and no fistula-related complication. Conclusions: Surgical closure of congenital coronary artery fistulas in adults can be performed with a very low risk, and closure is recommended to prevent complications.

CONGENITAL CORONARY ARTERY FISTULAS IN TURKISH PATIENTS UNDERGOING DIAGNOSTIC CARDIAC ANGIOGRAPHY

SUMMARYA coronary artery fistula is a direct communication between a coronary artery and one of the cardiac chambers or vessels around the heart. The present study was undertaken to define the incidence, clinical findings and angiographic characteristics of congenital coronary artery fistula in Turkish adults who underwent diagnostic cardiac angiography. A consecutive series of 11,350 coronary angiography, performed between January 2000 and December 2001, was retrospectively examined for the presence of coronary artery fistulas. The incidence of congenital coronary artery fistulas was 0.08%. All the patients had chest pain during exertion or at rest. All the fistulas were single and most arose from the proximal left anterior descending coronary artery and drained into the pulmonary artery. All the fistulas were small. Surgical treatment was not indicated. A congenital coronary artery fistula in adults is a distinct though rare entity, variable in its incidence and commonly associated with coronary artery obstructive disease. Diagnosis is mostly incidental during routine coronary angiography.