Treatment Of Coronary Artery Fistula Research Articles

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

BackgroundDespite 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.MethodsThis 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.ResultsOverall, 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.ConclusionsTrans-catheter approach for treating CAFs leads to appropriate long-term outcome with minimal potential side effects.

Coronary-Pulmonary Artery Fistula Recanalization on Coronary Computed Tomography Angiography Images.

Coronary computed tomography angiography (CCTA) is a non-invasive diagnostic method used (apart from the diagnosis of coronary artery disease) in the diagnosis of malformations of the coronary circulation and monitoring the effects of their treatment. In this paper, the authors present the case of recanalization of the coronary-pulmonary fistula, which was surgically closed in the past. This case highlights that follow-up CCTA after surgical treatment of coronary artery fistula should be performed in every patient. The recommendations regarding the frequency of such follow-up should be made.

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.

Abstract P232: Dilated Cardiomyopathy With Electrocardiographic Changes And Coronary-Pulmonary Fistula: An Uncommon Presentation Of Primary Aldosteronism In The Covid-19 Era

Primary aldosteronism is the most frequent forms of curable hypertension and elevated aldosterone levels have been associated with endothelial proliferation and pathological remodeling of the heart and arteries; however, coronary arterial abnormalities have never been reported in patients with primary aldosteronism. We report the case of a 53-year-old Caucasian obese man (BMI 37 Kg/m 2 ) with recent history of hypertension, fatigue and subjective dyspnea who was admitted to our hospital after performing an outpatient echocardiography that showed hypertensive and ischemic heart disease in dilated phase (LVEDVI 95 mL/m 2 ; LVEF 43%). His laboratory results showed hypokalemia (3 mmol/L) and an elevated aldosterone-renin ratio [(294 ng/L)/(1μU/mL)]. After case confirmation with saline infusion test, the abdominal CT scan showed a subcentimeter adenoma in the right adrenal gland. Surprisingly we noticed that, after oral potassium correction, the electrocardiogram revealed a symmetrical T-wave inversion and subsequently a coronary angiography detected a coronary artery fistula between the left anterior descending artery and the pulmonary artery in the absence of significant stenosis. In the Italy's CoViD-19 pandemic full spread, we preferred to postpone the diagnosis of the lateralization of aldosterone hypersecretion by adrenal vein sampling and we started a mineralocorticoid receptor antagonist with a clinical follow-up of cardiovascular symptoms for the optimal treatment of coronary artery fistula. After about two months of follow-up, the patient remains asymptomatic with good blood pressure control, normal potassium levels and significant echocardiographic improvement (LVEDVI 67 mL/m 2 ; LVEF 51%). Our case highlights a possible association between hypertensive patients with coronary artery fistulas and primary aldosteronism. We recommend cardiologists and clinicians to maintain a high level of suspicion of primary aldosteronism in these patients.

Anesthesia Management for a Patient with Coronary Artery Fistula and Huge Coronary Aneurysm Undergoing Off-Pump Surgery

CORONARY artery fistulas (CAFs) are abnormal communications between the coronary arteries and the cardiac chambers (coronary-cameral fistulas), coronary sinus, or vessels around the heart.1 The prevalence of CAFs in the general population is reportedly only 0.002%.2 CAFs may lead to coronary dilation or even aneurysmal malformation.3 The incidence of aneurysm in CAFs is reportedly only 14%.4 Surgical intervention is the primary treatment for CAFs with symptoms or complications. Surgical data about CAFs are limited owing to low incidence, and surgical techniques vary in different patients.

PP-256 Coronary Fistula between Left Anterior Descending (LAD) Arter to a cavity in Right Ventricule with Proximal LAD Lesion and Succesfully Treatment with Coil Embolisation and Coronary Stenting

Introduction: Coronary artery fistulas ( CAF) are rare, abnormal communications between coronary arterial bed and cardiac chambers or pulmonary circulation. Frequency have been reported as 0.05-0.25 % in coronary angiographic studies. Theraphy could be surgery, percutan closure with coil embolisation or occluder device, conservative management depend on fistul diameter and shunt flow. Mostly right coronary artery fistulate to right heart chambers or pulmonary artery. Fistulisation of LAD to a cavity in right ventricule is very rare. We introduce a a patient in this clinical condition with proximal LAD lesion that treated with coil embolisation and coronary stenting. Case: A 46 year old man appealed to our clinic cause of efor angina. In his echocardiogram a cavity was seen in right ventricule close to septumapical region ( Figure 1A). A coronary angiogram was done since his treadmill test positive. In his coronary angiogram LAD was aneurismatic, there was severe stenosis in proximal part of LAD ( Figure 1B, Video 1). Also LAD was continuing to apex and spilling a cavity suggested in right ventricule that was seen in echocardiogram (Figure 1C, Video 1). Cardiac computed tomography (CT) angiogram was confirmed that anatomy(Figure 1E,1F,1G). A decission was made to percutaneous intervention to LAD lesion and coil embolisation to fistul instead of surgery. Fistula was occluded succesfully with coil embolisation first (Figure 1D, Video 1), than stenting of proximal LAD was proceeded (Figure 1H, Video 1). Patient was discharged after two days uneventful following. Discussion: Treatment of CAF is challenging since large amount of variation an lack of guideline based treatment suggestions. Small fistulas which do not cause any symptom, heart chamber enlargment, pulmonary hypertension or cardiac ischemia could be followed medically. Large fistulas requires invasive treatment as surgery or percutaneous coronary intervention (PCI). PCI could be done with coil embolisation or amplatzer occlusion devices. Ligation of fistula with surgery in aneurismatic coronary arteries carries risk of coronary rupture. In our patient there was a severe narrowing at proximal part of LAD. We prefere PCI rather than one vessel by pass graft and fistula ligation surgery since LAD flow would diminish after ligation of fistula and that could impair negatively to graft functions. PCI has provided more physiologic coronary flow and succesful result.

Efficacy and safety of transcatheter coil embolization in congenital coronary artery fistulas guided by preinterventional cardiac computed tomography

Transcatheter coil embolization of coronary artery fistulas (CAFs) has emerged as an alternative to surgical closure despite limited data in the current literature. The aim of this study was to show the efficacy of CAF closure and the benefit of the combined preinterventional use of cardiac computed tomography and coronary angiography to evaluate the feasibility and enhance the safety of this procedure by obtaining precise information about the CAF anatomy. Five consecutive patients (three men, two women, age 51-68 years) with symptomatic angiographically proven CAFs were screened for transcatheter treatment and underwent preinterventional cardiac multidetector computed tomography (MDCT). On the basis of CAF-associated clinical symptoms, exercise-induced ischemia, coronary angiography, and cardiac MDCT, four of five patients with a CAF draining into the pulmonary artery system were considered eligible for transcatheter coil embolization, whereas in MDCT the fifth patient had multiple draining sites of the CAF and a relevant drainage into the right ventricular myocardium and was thus excluded from the procedure. Coil embolization was successfully performed in the remaining four cases without any complications. There was no residual flow through the CAF after the procedure. Clinical symptoms resolved almost completely in all four patients during a median 15.6-month follow-up. Transcatheter coil embolization is a feasible and effective method for the treatment of symptomatic CAFs in selected cases. The adjunctive preinterventional use of cardiac MDCT with conventional angiography can identify vessels that are anatomically applicable for transcatheter closure, defer therapy in morphologically unsuitable complex cases, and thus optimize the safety of the procedure.

全長にわたる瘤状拡大を伴った冠状動脈瘻の2例

要 旨：症例1は33歳，男性。右冠状動脈－左室瘻を認め，右冠状動脈は全長にわたり瘤化。左室拡大を伴う心不全があり，手術で瘻開口部の閉鎖と右冠状動脈の再建を行った。術後合併症なく独歩退院した。症例2は78歳，女性。右冠状動脈－冠状静脈洞瘻を認め，右冠状動脈は全長にわたり瘤化。1年後に心不全を発症し，手術を施行。瘻血管の結紮のみを行った。術後2年8カ月の現在も合併症なく経過している。

Percutaneous approaches to closure of coronary artery fistulas

Coronary artery fistula (CAF) is the most common hemodynamically significant congenital coronary anomaly. Blood is shunted from the coronary artery to a cardiac chamber, vein or intrathoracic vessel, bypassing the myocardial capillary network. The majority of the fistulas are small, and are detected incidentally and do not require intervention. The natural history of a CAF is variable and even spontaneous closure may be detected in rare cases. Treatment of CAF is indicated for symptomatic patients and for those asymptomatic patients with significant shunt or large fistulas that create risk for future complications, such as infective endocarditis, pulmonary hypertension or heart failure. Traditionally, surgery has been the main therapeutic method for the closure of CAF with proven efficacy and safety. However, since the first report of the use of percutaneous intervention in CAFs, many investigators have reported successful results using several techniques. Recent developments in the percutaneous closure m...

Transcatheter closure of coronary artery fistula using the new Amplatzer vascular plug and a telescoping catheter technique

Coronary artery fistulas (CAFs) are rare congenital or acquired anomalies characterized by an abnormal communication between the coronary arteries and the cardiac chambers or great vessels. Most patients are asymptomatic during childhood but symptoms and complications have been reported with advancing age. Until recently, surgery was the routine mode of treatment for CAFs but, today transcatheter closure is recommended using a variety of devices, such as occlusion coils, vascular plugs, umbrella devices and covered stents. The case described here is of a 47-year-old woman with a large bilateral CAF draining into the pulmonary artery, successfully treated by implantation of two Amplatzer vascular plugs using a telescoping catheter technique.

Congenital solitary coronary artery fistulas characterized by their drainage sites

Last centuries have witnessed tremendous sophistication and progress in the detection, diagnosis and treatment of coronary artery fistulas (CAFs). In many countries, CAFs were reported to be visualized and treated using several imaging techniques and different management strategies. Reports from nearly all continents of the globe have contributed to the description of CAFs, not only in Asia and Europe but also throughout North and Latin America. However, these reports have to be cautiously analyzed as many of them were published as a case report and careful interpretation is warranted due to possible publication bias. A literature search was performed using PubMed search interface to select papers dealing with congenital CAFs in adult population between 2000-2009. A total of 233 subjects were collected, and analysed according to their drainage site and treatment modality. They were divided into two subgroups: percutaneous transluminal embolization group (PTE group, n = 122) and surgical ligation group (SL group, n = 111). In the SL group, atherosclerotic coronary artery disease (19%) and associated congenital lesions (23%) were more prevalent compared with the PTE group (9% and 8%), respectively. Infective endocarditis was more frequently seen in the SL group besides syncope, congestive heart failure and hemopericardium. In both groups multimodality diagnostic workup composed of several non-invasive and invasive imaging techniques for fistula visualization were performed and drainage sites into the different cardiac chambers and intrathoracic great vessels were similarly distributed in the two groups.

Fístula entre artéria coronária interventricular anterior e o tronco arterial pulmonar: tratamento cirúrgico de cinco pacientes

The current study reports on the operative experience of patients with coronary artery fistulas between the anterior intraventricular coronary artery and pulmonary trunk. Of the five patients operated, 60% were women and the ages ranged form 40 to 46 years old. Stress echocardiogram and coronary cineangiography were accomplished for all patients. No deaths occurred in the postoperative period nor were symptoms reported. We believe that the surgical procedure is the first choice treatment for coronary artery fistulas, as it safely and effectively prevents the complications of arteriovenous shunts.

Midterm Outcome of Percutaneous Transcatheter Coil Occlusion of Coronary Artery Fistula

The mid- to long-term outcome of pediatric patients with coronary artery fistula (CAF) after transcatheter closure remains unknown. This study reports the midterm outcome of CAF closure by transcatheter Gianturco coil occlusion in pediatric patients. Eighteen patients with CAF confirmed by coronary angiography were seen in our institution. Among them, 4 patients who had persistent coronary artery dilatation received transcatheter Gianturco coil occlusion (age range, 25 months to 12 years; mean, 4.6 years). Two were closed with a single coil, and two were closed with two coils. No residual shunts were detected on follow-up angiography and echocardiography immediately after coil occlusion in all cases. Follow-up Doppler echocardiography (4/4) and angiography (3/4) showed persistent CAF occlusion in all 4 patients. Two of 3 patients with coexistent aneurysmal formation showed obliteration of the aneurysm on angiographic follow-up. In addition, 2 showed resumption of normal coronary arterial size, and 2 showed decrement of the coronary arterial diameter. All 4 patients had normal ECG findings after 26-83 months (mean, 49 months) of follow-up, and all were in NYHA functional class I. The midterm outcome of percutaneous transcatheter coil occlusion in the treatment of CAF is excellent.

Surgical treatment of coronary artery fistulas: 15 years' experience.

We report our experience of surgical treatment of coronary artery fistula and focus on the electrocardiographic changes that may be seen postoperatively. Between 1988 and 2003, cardiac operations were carried out on 9,487 patients, of whom 21 had a coronary artery fistula. The mean age of these 21 patients was 36.8 +/- 4.9 years. The fistula originated from the right coronary artery in 9 cases and from the left side in 12. The fistulous connection was to the right ventricle in 5 patients, to the right atrium in 6, to the pulmonary artery in 8, and to the coronary sinus in 2. There was no operative mortality. Two patients (10%) had nonspecific electrocardiographic changes during the postoperative period. Repeat coronary angiography revealed normal coronary anatomy in both, and their electrocardiograms normalized within 2 months. Patients suspected to have myocardial ischemia related to the surgical procedure, with ST segment depression or T wave abnormalities on the electrocardiogram, should undergo repeat angiography to eliminate the possibility of coronary artery damage.

Congenital coronary artery fistulas: clinical considerations and surgical treatment.

Coronary artery fistulas are uncommon abnormalities that can cause significant cardiac morbidity. Indications for operation vary, particularly, for asymptomatic patients. Early surgical correction is indicated because of the high incidence of late symptoms and complications. From January 1981 to December 2001, all 15 patients who underwent surgical management of congenital coronary artery fistulas at the Tri-Service General Hospital, Taipei, Taiwan, China were included in the present retrospective study. Twelve patients were symptomatic at the time of the diagnosis. Coronary artery fistulas involved the right coronary artery in five patients, left coronary artery in nine, and both the right and the left coronary arteries in one. Coronary artery fistula drained into the right ventricle in seven patients, right atrium in three, pulmonary artery in two, left ventricle in one, left atrium in two, and coronary venous sinus in one. The value of pulmonary blood flow/systemic blood flow ranged from 0.98 to 2.1. Six patients had associated cardiac anomalies. All patients received surgical correction. Nine patients received cardiopulmonary bypass during operation. There was zero operative mortality and operative morbidity was low. All patients had a stable condition and were asymptomatic during a mean postoperative follow-up of 13.3 years. Early surgical treatment for coronary artery fistulas is safe and effective. The risk of operative correction appears to be considerably less than the potential for development of serious and potentially fatal complications, even in asymptomatic patients.

Outcomes of transcatheter embolization in the treatment of coronary artery fistulas

Outcomes of transcatheter embolization in the treatment of coronary artery fistulas

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.

Surgical Treatment of Coronary Artery Fistula

Six patients with coronary artery fistula were treated surgically between October 1977 and November 1998. The clinical manifestations, diagnostic criteria, indications for operation, and surgical techniques were evaluated. One patient died from ventricular fibrillation on the 2nd postoperative day. The outcome for the other 5 patients was good; symptoms and heart murmurs disappeared and all are alive and well after 10 to 21 years of follow-up. It was concluded that analysis of clinical data can confirm the diagnosis and this condition can be treated satisfactorily by suitable surgery.

Transcatheter embolization in the treatment of coronary artery fistulas

Seven patients with a coronary artery fistula underwent percutaneous transcatheter embolization (five were male and two female; the age range was 2 to 67 years [median 17]). Three patients were symptomatic. The left to right shunt ranged from 1.6 to 2.6:1. In six patients, the fistula was an isolated congenital anomaly; in one, it was acquired. The fistula arose from branches of the left (n = 5) and right (n = 2) coronary arteries and drained to the right ventricle (n = 2), right atrium (n = 2), coronary sinus (n = 1), pulmonary artery (n = 1) and a bronchial artery (n = 1). Different embolization techniques were used to occlude eight feeding arteries. The embolization materials included a detachable balloon (n = 3), coaxial embolization with platinum microcoils (n = 3), a combination of detachable balloon and microcoil (n = 1) and standard steel coils (n = 1). Satisfactory occlusion was achieved in six patients. In one case, the valve of the detachable balloon was damaged, resulting in early balloon deflation and a residual fistula. There were no associated complications in any patient. Follow-up investigation by Doppler ultrasound or coronary angiography 4 months to 4 years later showed that permanent occlusion was achieved in all six patients in whom embolization was initially successful. Transcatheter embolization should be considered the treatment of choice for coronary artery fistulas.

Diagnosis of coronary artery fistula by two-dimensional echocardiography, pulsed doppler ultrasound and color flow imaging

Ten consecutive patients with a coronary artery fistula, aged 1 day to 4 years, were studied by two-dimensional echocardiography, pulsed Doppler ultrasound and color flow imaging. All patients underwent cardiac catheterization, and seven patients had surgical closure of the fistula. The origin, course and site of drainage of the coronary artery fistula were correctly identified prospectively by echocardiographic examination in all patients. Color flow imaging was particularly helpful in visualizing the site of drainage of the fistula.Diameters of the right and left coronary arteries at their origin and of the aortic root were measured from two-dimensional echocardiographic frames and compared with measurements obtained in normal children. The ratio of coronary artery diameter to aortic root diameter in normal children was 0.14 ± 0.03 (mean ± SD) for the right coronary artery and 0.17 ± 0.03 for the left coronary artery. These normal ratios were greatly exceeded for coronary arteries feeding the fistula, and ranged from 0.68 to 0.84 for the right coronary artery and from 0.34 to 0.52 for the left coronary artery.All anatomic information needed for surgical treatment of coronary artery fistula was consistently obtained by echocardiography with color flow imaging. The fistula was closed from within the heart in five patients and by ligation from the epicardial surface in two patients. In these latter patients, intraoperative color flow imaging at the time of ligation proved to be extremely valuable in achieving complete closure.