Transcatheter closure of coronary artery fistula: A 21‐year experience

Abstract

Objectives: To evaluate the outcomes of transcatheter coronary artery fistula (CAF) closure and to identify anatomic/procedural factors that may impact outcomes. Background: Due to the rarity of CAF, reported experience with transcatheter closure remains limited and anatomic and procedural factors that may lead to unsuccessful closure, complications, or recanalization of CAF are unclear. Methods: All patients who underwent transcatheter CAF closure at Mayo Clinic from 1997 to 2018 were retrospectively reviewed. CAF anatomic characteristics, procedural techniques, and clinical/angiographic outcomes were assessed. Results: A total of 45 patients underwent transcatheter closure of 56 CAFs. The most commonly used devices were embolization coils in 40 (71.4%) CAFs, vascular occluders in 10 (17.8%), or covered stent in 2 (3.6%). Acute procedural success with no or trivial residual flow occurred in 50 (89.3%) CAFs. Residual flow was small in three (5.4%) and large in three (5.4%). Eight (17.8%) patients had complications, including device migration in three, intracranial hemorrhage from anticoagulation in one, and myocardial infarction (MI) in four. MI was a result of covered stent thrombosis or stagnation of flow after closure of large distal CAF. Twenty-two patients with 27 CAFs had followup angiography after successful index procedure at median time of 423 (IQ 97-1348) days. Of these, 23 (85.2%) had no/trace flow and 4 had large flow from recanalization. Conclusions: Transcatheter CAF closure is associated with a favorable acute procedural success and complication rate in selected patients. Procedural success and risk for complication are highly dependent on CAF anatomy and closure technique.

Transcatheter Occlusion of a Giant Coronary Artery Fistula in a Neonate

“…Although right coronary artery-to-right ventricle shunting persisted after transcatheter therapy of the fistula in our case, post-procedural improvement was substantial. In a 21-year experience of transcatheter therapy of coronary artery fistula at the Mayo Clinic, 3 of 16 patients who had an acute persistent shunting of trivial grade showed an increase in residual flow during the follow-up period [ 4 ]. In a study of 15 years of transcatheter treatment at another institution, of the 9 patients who required re-intervention, the reason of re-intervention was persistent shunting only in 1, and those included myocardial ischemia, device embolization, and valve injury in the others [ 8 ].…”

“…The presence of congestive heart failure and/or distal coronary insufficiency warrants therapeutic interventions such as transcatheter occlusion or open surgical ligation on the coronary artery fistula [ 2 , 3 ]. Transcatheter occlusion of coronary artery fistulas is associated with good short-term procedural success rates and complication rates in selected patients [ 4 ]; however, reports on successful outcomes during the neonatal period are limited [ 2 , 5 , 6 ]. Here, we describe the transcatheter management of a neonate who developed congestive heart failure associated with a giant right coronary artery-to-right ventricle fistula.…”

Coronary Artery Fistula

“…Small single-center studies suggest older age at time of closure, distal origin of the CAF off the coronary artery, and CAF drainage into the CS have a higher association with post-closure MI, all of which were present in our patient ( 4 , 5 ). Timing of MI is variable and has been described both early and late after closure ( 4 , 5 , 6 ). Valente et al.…”

“…El-Sabawi et al. ( 6 ) described 45 patients that underwent transcatheter closure of CAF that resulted in 2 cases of post-closure MI thought to be secondary to stagnation of flow in the dilated coronary artery despite adequate anticoagulation. Gowda et al.…”

Left Main Coronary Artery to Superior Vena Cava Fistula Unmasked by Endarteritis

“…LMCA to SVC arteriovenous fistulas are rare, with large case series reporting <2% incidence among all patients with coronary AVFs ( 1 ). In symptomatic patients with indications for closure, a multidisciplinary approach is recommended ( 2 ).…”