Coronary artery fistulas: How to manage them

Latson, Larry

doi:10.1002/ccd.21125

Cited by 182 publications

(230 citation statements)

References 29 publications

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“…Fistulas are occasionally encountered during CAG; however, they are usually large and visible. The majority of coronary fistulas are congenital and some coronary fistulas are acquired after infection, trauma, and iatrogenic injury, however, many minute fistulas can remain undetectable [1]. Based on this patient' s previous history of CAB graft surgery, it is possible that this coronary fistula was a result of that procedure.…”

Section: Discussionmentioning

confidence: 97%

Angiographical Changes Induced by Tiny Coronary Fistula

Saigusa

Matsuo

Suzuki

2017

Cardiovasc Imaging Asia

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An 82-year-old female presented with angina pectoris due to mid-right coronary artery (RCA) stenosis. Percutaneous coronary intervention (PCI) was performed with optical coherence tomography (OCT). When OCT was performed with manual coronary flushing to obtain a clearer image, the contrast media seemed to extravasate from the coronary artery, resembling a coronary perforation; however, the patient did not have any chest pain and her vital signs were stable. Coronary angiography (CAG) performed immediately after the finding showed no abnormalities and the final CAG did not show any abnormalities. Coronary computed tomography angiography after PCI revealed a micro-fistula from the RCA to the right ventricle. With normal injection pressure, contrast did not show the tiny coronary fistula, but it was detectable with high pressure. Our report represents an abrupt angiographical change due to a tiny coronary fistula.

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Section: Discussionmentioning

confidence: 97%

Angiographical Changes Induced by Tiny Coronary Fistula

Saigusa

Matsuo

Suzuki

2017

Cardiovasc Imaging Asia

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“…2,3 Various percutaneous devices are available including detachable balloon, coil embolization, and graft stents. 2,[4][5][6] Due to the presence of a large pseudoaneurysm, the use of a stent graft appeared to be the best approach in this patient.…”

Section: Discussionmentioning

confidence: 99%

Traumatic Coronary Artery Fistula Closure with Stent Graft

Safi

Ebrahim

Namazi

et al. 2012

Methodist DeBakey Cardiovascular Journal

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We present a rare case of a symptomatic acquired large coronary fistula and aneurysm secondary to chest trauma that was successfully closed using stent graft. This case is followed by review of the literature. Case ReportA 30-year-old man suffering from a penetrating stab wound to his mid-left-anterior chest wall underwent left lateral thoracotomy at the fourth intercostal space to repair his chest wall injury. No clear cardiac injury was identified at that time. After surgery, the patient developed increasing exertional angina that limited his activities. He was referred for further evaluation 5 months after his trauma due to persistent symptom. His physical exam was remarkable for a loud grade III/IV continuous murmur that was heard at left sternal border. ECG was normal. Chest X-ray showed mild cardiac enlargement. Coronary angiography revealed a large coronary pseudoaneurysm and fistula originating from mid left anterior descending artery (LAD) connecting to the right ventricular cavity (Figures 1 and 2). Distal LAD after the fistula was very small due to poor distal flow. The decision was made to close the fistula using a stent graft.The left main coronary artery was engaged using a JL3. 5 guiding catheter. After wiring the LAD, a 3-mm x 20-mm compliant balloon was inflated at the side of the fistula to determine successful closure with contrast injection during balloon inflation. Next, a 3-mm x 26-mm coronary GraftMaster stent was implanted at the aneurysm neck level, followed by balloon dilatation using a 3-mm x 18-mm Sapphire balloon. The aneurysm was completely sealed after stenting, with restoration of normal flow into the distal LAD ( Figure 3). The patient tolerated the procedure and remains asymptomatic during follow-up visits. DiscussionLarge coronary artery fistulas are rare, and the true incidence is difficult to discern as a great number of them are asymptomatic. At least 75% of coronary artery fistulas are small and clinically silent. Most are congenital while some are acquired, as was the case presented herein. Coronary fistulas cause blood flow to be shunted into cardiac chambers, great vessels, or other structures, bypassing the myocardial capillary network. Symptoms may be caused by either coronary steal or a high left to right shunt flow. In symptomatic patients, closure of the fistula should be considered. 1Physical examination is normal in typical patients. In the case of a very large fistula, a widened pulse pressure may be detected, and a continuous murmur may be heard similar to our case. On rare occasions, thoracic trauma can lead to coronary artery fistula. In our case, coronary fistula occurred in the setting of a stab wound penetrating the chest. Trauma-related coronary fistulas usually are connected to right-sided heart structures. In large fistulas similar to our case, coronary steal is the presumed cause of symptoms.

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“…The use of this type of embolisation method should be restricted to interventionalists experienced in its usage. (1) Large fistulas, which are more than 3 times the expected size for the patient, (18) with a relatively straight course may be treated with large occlusion devices such as the Amplatzer vascular plug using an arteriovenous guidewire circuit (Case 1). (16) Anterograde deployment of the device is possible through a large sheath.…”

Section: Discussionmentioning

confidence: 99%

“…(18) Myocardial infarction due to thrombus formation in dilated CAF channels has been reported months (Case 1) to years after surgical closure of CAF. A 26-year-old male patient reported in the literature with a large LAD to right ventricle CAF, underwent surgical closure of a 10mm orifice from within the dilated LAD.…”

Section: Discussionmentioning

confidence: 99%