Download Transcatheter closure of coronary artery fistula using the new

Case report
Transcatheter closure of coronary artery fistula using the new
Amplatzer vascular plug and a telescoping catheter technique
Antonella De Santis, Alberta Cifarelli and Roberto Violini
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.
Introduction
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.
The majority of CAFs are congenital but may occasionally be detected following cardiac trauma or iatrogenic
factors (cardiac surgery, coronary angioplasty, therapeutic
chest irradiation, etc.) [1–3]. The estimated incidence in
selected patients, submitted to coronary angiography,
ranges from 0.3 to 0.8% [4]. Most fistulas arise from
the right coronary artery (60%) and terminate in the right
side of the heart (90%). Most patients are usually asymptomatic during childhood but, in older patients, late
symptoms and complications, such as myocardial ischemia, pulmonary arterial hypertension, cardiac heart failure, arrhythmias, endocarditis and rupture with cardiac
tamponade, have been reported [4–7]. Symptoms, complications and a significant shunt are the main indications
for the treatment of CAFs [1].
Since transcatheter occlusion of fistulas was first reported
in the 1980s [8,9], it has been considered an alternative to
surgery, with excellent results and acceptable complication rates. Various closure devices are available but coil
occlusion of the fistula is currently the most commonly
used technique [10–12]. The Amplatzer vascular plug
(AVP) (AGA Medical Corp., Golden Valley, Minnesota,
USA) is a new occlusion device made of self-expanding
cylindrical nitinol wire mesh secured at both ends with
platinum marker bands. A stainless steel delivery cable,
1558-2027 ß 2010 Italian Federation of Cardiology
J Cardiovasc Med 11:605–609 Q 2010 Italian Federation of
Cardiology.
Journal of Cardiovascular Medicine 2010, 11:605–609
Keywords: coronary fistula, transcatheter closure, vascular plug
Interventional Cardiology, Department of Cardiovascular Medicine, S. Camillo
Forlanini Hospital, Rome, Italy
Correspondence to Dr Roberto Violini, Interventional Cardiology, Department of
Cardiovascular Medicine, Azienda Ospedaliera San Camillo Forlanini,
Circonvallazione Gianicolense n 87, CAP 00152 Rome, Italy
Tel: +39 06 58704478; fax: +39 06 58704478;
e-mail: [email protected]
Received 26 April 2009 Revised 9 July 2009
Accepted 26 July 2009
135 cm in length, is attached to the microscrew located on
one of the marker bands. The vascular plug is preloaded,
attached to the delivery cable (Fig. 1). The AVP is
available in various sizes, ranging from 4 to 16 mm in
diameter (in 2 mm increments) and from 7 to 8 mm in
length. The selected vascular plug should be 30–50%
larger than the diameter of the target vessel. For delivery,
a 5–8 French (F) standard coronary guide catheter can be
used; the recommended internal diameter being from
0.056 to 0.088 inches. Until its delivery, the plug can be
repositioned or removed if the position is not satisfactory.
The present report refers to a case of bilateral fistula
submitted to treatment with the new AVP and a complex
delivery technique.
Case report
A 47-year-old woman was referred to our institute on
account of a history of chest pain and dyspnea upon
moderate exertion. At physical examination, a continuous
murmur could be heard over the precordium at the
second left intercostal space. Transthoracic color Doppler
echocardiogram revealed a continuous flow in the main
pulmonary artery, in the high parasternal short axis view.
Contrast-enhanced electron-beam tomography disclosed
the presence of a tortuous and enlarged vascular malformation emerging from the left anterior descending
(LAD) artery to the pulmonary artery.
A selective coronary angiography was, therefore, performed using 6F right Judkins and left Judkins catheters
(Cordis Corporation, Miami, Florida, USA), which
DOI:10.2459/JCM.0b013e3283313504
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
606 Journal of Cardiovascular Medicine 2010, Vol 11 No 8
Fig. 1
Fig. 2
The AVP is made from 144 nitinol mesh. AVPs range in size from 4 to
16 mm in diameter in 2 mm increments and is 7–8 mm in length. The
vascular plug is selected to be 30–50% larger than the target vessel
diameter for secure delivery and occlusion.
demonstrated a large bilateral coronary artery fistula
draining into the pulmonary artery (Fig. 2a, b). The right
fistula, arising alongside the ostium of the right coronary
artery, had a large diameter and was located in front of the
right ventricular ejection tract, towards the left section of
the fistula, and was divided into two branches (superior
and inferior) before draining into the pulmonary artery.
The left fistula, uniformly dilated, arose from the middle
portion of the LAD artery and, after a very tortuous
crossing, drained into the main pulmonary artery. The
proximal part of the LAD appeared dilated whereas the
distal part showed normal dimensions. The right and left
fistulas had a maximal diameter of 8 and 5 mm, respectively, with the narrowest diameters (proximal to the
entrance into the pulmonary artery) of 5 and 4 mm,
respectively. Coronary angiography did not show any
evidence of atherosclerotic stenosis in the coronary
arteries and no additional cardiac diseases were found.
Left to right shunting, assessed by measuring the pulmonary to systemic flow ratio (QP : QS) was found to be
1.2. Given the referring symptoms and in order to prevent
later complications, it was decided to attempt percutaneous closure of the CAF, as reported in the literature
[1,13].
Closure of the CAF was performed in two steps. In the
first, closure of the right part of the fistula was attempted
following cannulation of the anomalous collector from the
right femoral artery with a 7F Amplatz (AL) II guiding
catheter (Launcher, Medtronic, Inc., Minneapolis, Minnesota, USA); the AVP (diameter 8 mm, length 6 mm)
was advanced to the proximal side of the superior branch;
Selective coronary angiography of a right (a) and left (b) coronary artery
fistula draining into the main pulmonary artery.
at the same time, dissection, with spontaneous occlusion
of the inferior branch of the fistula, was observed. Angiography, performed 15 min later, confirmed the correct
position of the device and occlusion of both branches of
the fistula; the AVP was then released from the delivery
cable (Fig. 3). During the delivery of the device, a
transient elevation of the ST segment was observed in
the inferior leads with angina and angiographic evidence
of slow-flow in the right coronary artery, probably due to
air embolization that resolved spontaneously. During the
procedure the patient received intravenous (i.v.) heparin,
achieving an activated clotting time of more than 250 s.
After delivery of the device, aspirin (250 mg i.v.) was
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
Transcatheter coronary artery fistula closure De Santis et al. 607
Fig. 3
Released AVP allows complete occlusion of the right CAF.
administered. Total fluoroscopy time was 21 min. No
postprocedural complications were observed and the
patient was discharged 2 days later after a chest radiograph, standard ECG and Doppler echocardiographic
study. Therapy with aspirin was prescribed to prevent
eventual thromboembolic events.
Closure of the left CAF was performed 2 months later, at
the request of the patient. Because of the origin of the left
CAF from the middle portion of the LAD artery and in
order to avoid a deep intubation of the artery, necessary
for a correct delivery of the AVP, we decided to use a
microcoil Micrusphere Platinum (Micrus Endovascular,
Sant Jose, California, USA) as a first choice. From
the right femoral artery, the LAD was cannulated with
a 8F AL II guiding catheter (Launcher, Medtronic, Inc.)
and a guide wire (BMW, Abbott Vascular, Santa Clara,
California, USA) was positioned within the anomalous
collector. A microcatheter VASCO 2.1 F (AB Medica,
Balt Extrusion INC, Montmorency, France) was
advanced over the guide wire to the fistula and the
guide wire was then removed; thereafter a microcoil
Micrusphere Platinum 10 17.1 mm (Micrus Endovascular) was introduced to the narrowest segment of the
fistula. Due to the large dimensions of the fistula and
the high flow, stabilization of the coil was impossible.
The guide wire was, therefore, reintroduced into the
fistula, a second microcatheter VASCO 2.1 F (AB Medica,
Balt Extrusion Inc.) was advanced parallel to the first
one and a second microcoil Micrusphere Platinum
8 13.6 mm (Micrus Endovascular) was introduced in
an attempt to occlude the malformation with the two
coils simultaneously. The procedure was complicated
by the migration into the pulmonary artery of one of
the two coils (microcoil 10 17.1 mm), which was recovered using a 10.5 15 mm snare catheter advanced from
the femoral vein to the pulmonary artery. An alternative
method, a ‘telescoping catheter technique’, was then
employed. The left coronary ostium was cannulated with
an 8F left Judkins guiding catheter (Cordis Corporation),
a guide wire (Wispher, Abbott Vascular) and the microcatheter VASCO were positioned distally into the fistula.
A 5F right Judkins 3.5 guiding catheter was advanced in
the 8F guiding catheter to the proximal part of the fistula
(in the middle portion of the LAD) over the microcatheter, to maintain a more central position in the lumen and
to avoid coronary dissections. The telescoping catheter
technique was possible by prolonging the 5F guiding
catheter, cutting the proximal hub and inserting a 5F
introducer. The VASCO microcatheter and the guide
wire were removed and an AVP (diameter 8 mm, length
6 mm) was then advanced in the 5F-guiding catheter into
the fistula to the desired site of occlusion. Some minutes
later, once the device was in the correct position, with
almost complete occlusion of the fistula and absence of
any obstruction in the LAD had been confirmed, the AVP
was released (Fig. 4a). The final angiography confirmed
an optimal result with TIMI grade III coronary flow
(Fig. 4b).
Fluoroscopy time was 40 min. This reflects the potential
difficulty of these complex procedures.
As is practice, during the procedure, heparin and aspirin
were administered i.v. No postprocedural complications
were observed.
Five days later, a coronary angiography confirmed that no
major side branches had been negatively affected by the
plug which was in the correct position. A very small
residual shunt was observed in the left artery fistula
whereas a new, small, right artery fistula was demonstrated.
The patient received aspirin for 6 months after the
procedure.
Discussion
Fistulas are rare congenital or acquired, sometimes iatrogenic, anomalies of coronary arteries. The presence of
symptoms, complications and a significant shunt are the
main indications for coronary artery fistula closure. The
first pathological account of CAF was published, in 1908,
by Maude Abbott and the first successful surgical closure
of a CAF was performed, in 1947, by Bjork and Crafoord,
in a patient with a preoperative diagnosis of patent
ductus arteriosus [14]. Since then, surgery has been the
technique of choice in the treatment of CAF [15–17];
however, today, technical progress in interventional
cardiology has allowed transcatheter closure in selected
patients, with good success rates and an acceptable
procedure-related morbidity. Various devices including
Gianturco coils (Cook, Inc., Bloomington, Indiana, USA),
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
608 Journal of Cardiovascular Medicine 2010, Vol 11 No 8
Fig. 4
Closure of the left CAF by the ‘telescoping catheter technique’ (a). A 5F
right Judkins 3.5 guiding catheter (arrow A) advanced in an 8F guiding
catheter (arrow B) to the middle part of the LAD, and AVP (arrow C)
advanced in a 5F guiding catheter into the fistula to the preferred site of
occlusion. AVP positioned in the right CAF (arrow D). Once the correct
position of the device and the absence of any obstruction in the LAD
were confirmed, the AVP was released, resulting in occlusion of the
CAF and maintenance of TIMI III coronary flow (b).
Grifka Vascular Occlusion Device (Cook, Inc.), and
Amplatzer Occlusion Devices (AGA Medical Corp.) have
been described in the treatment of arteriovenous malformations. In a few studies, the use of AVP in the closure
of CAF has been investigated, all of which confirm that it
could be regarded as a well-tolerated and effective technique for this purpose [18–20]. The AVP is easy and fast
to use and can be repositioned safely before final delivery
if the placement is not satisfactory. In comparison, occlusion using coils sometimes requires complex manipula-
tion of catheters, as well as the selection of various
catheters and wires. The AVP is especially useful for
embolization of short, high-flow vessels such as large
arteriovenous malformations or large coronary fistulas
where multiple coils may be needed to occlude the
malformation and coil migration and catheter dislodgement might occur [12]. The AVP does not cause immediate thrombosis and in high-flow situations complete
occlusion is usually obtained within 15 min [21]. Furthermore, the plug can be delivered easily through a small, 5F
or 6F, guiding catheter. Our experience has further
confirmed the efficacy and safety of AVP in the treatment
of CAF. In our case, AVP was used in a simpler procedure
(right CAF closure), where the fistula was proximal and
the AVP was easily delivered, and in a very difficult
procedure (left CAF closure) in a large, tortuous and
distal fistula in which multiple coils would be needed
to occlude the malformation, but it was impossible to
stabilize these on account of the high flow. The AVP is
more difficult to implant in distal fistulas as a stiff delivery
catheter must be advanced distally in the vessel to the
location where the AVP must be delivered. In our case,
we found that it may be preferable to use two coronary
guiding catheters like a ‘telescope’, first cannulating the
coronary ostium with a large 8F catheter, then introducing and advancing inside it a smaller 5F guiding catheter
as the delivery catheter. This technique, which, to our
knowledge, has only once been reported previously in a
similar case of coronary fistula occlusion [12], may be
more traumatic but has the advantage of allowing welltolerated release of the device. However, to minimize the
risks of coronary dissection, we advanced the smaller
guiding catheter over a guide wire and a microcatheter
in order to maintain a more central position in the lumen.
Results of the procedure were excellent and no
complications occurred.
In conclusion, the AVP seems to be operator-friendly,
simple to use in tortuous vessels, employing a coronary
guiding catheter in the proximal fistulas and a telescoping
technique in the more distal fistulas, thus obtaining
complete occlusion of the CAF. Given the variability
of anatomy seen in CAFs, the need to apply different
techniques for device delivery, as well as the ability to
manage various complications, suggest that no single
transcatheter method is likely to be successful in all
cases and flexibility in the interventional approach is
important.
Acknowledgements
All figures were produced with the help of the radiology
technicians. The authors are particularly grateful to Miss
Ilaria Scancella.
References
1
Balanescu S, Sangiorgi G, Castelvecchio S, Medda M, Inglese L. Coronary
artery fistulas: clinical consequences and methods of closure. A literature
review. Ital Heart J 2001; 2:669–676.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
Transcatheter coronary artery fistula closure De Santis et al. 609
2
3
4
5
6
7
8
9
10
11
Quatrini I, Zacà V, Mondillo S. Coronary artery-pulmonary artery fistula:
case report. Cardiovascular Ultrasound 2007; 5:19.
Quereshi SA. Coronary arterial fistulas. Orphanet J Rare Dis 2006;
1:51.
Gowda RM, Vasavada BC, Khan IA. Coronary artery fistulas: clinical and
therapeutic considerations. Int J Cardiol 2006; 107:7–10.
Moro-Serrano C, Martinez J, Madrid AH, Rufilanchas JJ, Novo L, Marin
Huerta E, et al. Ventricular tachycardia in a patient with congenital coronary
arteriovenous fistula. Am Heart J 1992; 124:503–505.
Corvaja N, Moses JW, Vogel FE, Javit DJ, Ziolo G, Frumkin WJ, et al.
Exercise-induced ventricular tachycardia associated with coronary
arteriovenous fistula and correction by transcatheter coil embolization.
Catheter Cardiovasc Interv 1999; 46:470–472.
Liberthson RR, Sagar K, Berkoben JP, Weintraub RM, Levine FH.
Congenital coronary arteriovenous fistula. Report of 13 patients,
review of literature and delineation of management. Circulation 1979;
59:849–854.
Reidy JF, Sowton E, Ross DN. Transcatheter occlusion of coronary to
bronchial anastomosis by detachable balloon combined with coronary
angioplasty at same procedure. Br Heart J 1983; 49:284–287.
Reidy JF, Anjos RT, Qureshi SA, Baker EJ, Tynan MJ. Transcatheter
embolization in the treatment of coronary artery fistulas. J Am Coll Cardiol
1991; 18:187–192.
Qureshi SA, Tynan M. Catheter closure of coronary artery fistulas. J Interv
Cardiol 2001; 14:299–307.
Armsby LR, Keane JF, Sherwood MC, Forbess JM, Perry SB, Lock JE.
Management of coronary artery fistulae. Patient selection and results of
transcatheter closure. J Am Coll Cardiol 2002; 39:1026–1032.
12
13
14
15
16
17
18
19
20
21
Collins N, Mehta R, Benson L, Horlick E. Percutaneous coronary artery
fistula closure in adults: technical and procedural aspects. Catheter
Cardiovasc Interv 2007; 69:872–880.
Latson AL. Coronary artery fistulas: how to manage them. Catheter
Cardiovasc Interv 2007; 70:110–116.
Bjork G, Crafoord C. Arteriovenous aneurysm on the pulmonary artery
simulating patent ductus arteriosus botalli. Thorax 1947; 2:65–68.
Kamiya H, Yasuda T, Nagamine H, Sakakibara N, Nishida S, Kawasuji M,
et al. Surgical treatment of congenital coronary artery fistulas: 27 years’
experience and a review of the literature. J Card Surg 2002; 17:173–177.
Malekahmadi M, Shahmohammadi A. Surgical outcome of coronary artery
fistulas repair in children. Pediatr Cardiol 2005; 26:328–330.
Tirilomis T, Aleksic I, Busch T, Zemker D, Ruschewski W, Dalichau H.
Congenital coronary fistulas in adults: surgical treatment and outcome. Int J
Cardiol 2005; 98:57–59.
Fisher G, Apostolopoulou AC, Rammos S, Kiaffas M, Kramer HH.
Transcatheter closure of coronary arterial fistulas using the new Amplatzer
vascular plug. Cardiol Young 2007; 17:283–287.
Hill SL, Hijazi ZM, Hellenbrand WE, Cheatham JP. Evaluation of the
Amplatzer vascular plug for embolization of peripheral vascular
malformations associated with congenital heart disease. Catheter
Cardiovasc Interv 2006; 67:113–119.
Subramanyam K, Kapoor R, Radhakrishnan S, Bhandari S. Use of
Amplatzer vascular plugs in the closure of coronary arteriovenous fistula
[abstract]. Indian Heart J 2005; 57:288.
Tuite DJ, Kessel DO, Nicholson AA, Patel JV, McPherson SJ, Shaw DR.
Initial clinical experience using the Amplatzer vascular plug. Cardiovasc
Intervent Radiol 2007; 30:650–654.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.