1. Percutaneous Closure of a Coronary Fistula
John Lasala MD, PhD Director, Interventional Cardiology

2. Case
56 year-old WF
CC: Left sided CP lasting 5-10min; not associated with exertion
PMHx:
DM2
Hyperlipidemia
SHx: Positive for Tobacco use
FHx: Positive for premature CAD
Prior work-up: EBCT – 600 Agaston Units

3. Case - LHC (AP Caudal)

4. Case – LHC (LAO Caudal)

5. Case – LHC (AP Cranial)

6. Case – LHC (LAO view of the RCA)

7. Case – LHC (RAO view of RCA)

8. Case LHC RHC no significant CAD
Complex coronary fistulas between the LAD and RCA with the pulmonary artery
RHC
Qp/Qs – 1.3
5% step up from the RV to the PA
Elevated right sided pressures – PA 42/21 mmHg

9. Coronary Fistulas Rare PE – continuous murmur Clinical Presentation
% of all congenital cardiac defects
% of patients undergoing coronary angiography
PE – continuous murmur
Clinical Presentation
>50% of patients are asymptomatic
Most patients have small Qp/Qs, normal pulmonary and systemic pressures at time of diagnosis
Occurrence of symptoms correlates with larger shunts
In patients with CAD, even small Qp/Qs can exacerbate angina
Symptoms and complications are rare in young patients but increase significantly with age.

10. Coronary Fistulas Potential Complications Clinical Course Management
Angina (coronary steal)
Congestive heart failure
Rupture
Myocardial Infarction
SBE
Clinical Course
Most untreated patients will develop symptoms and/or fistula related complications
Surgical ligation at an older age is associated with increased morbidity and mortality
Management
Elective closure/ligation is recommended in most patients

11. Case Patient referred for percutaneous closure of the A-V fistulas.
Attempts at coil embolization were unsuccessful due to the serpiginous nature of the fistulous tracks.

12. What would be your next recommendation?

13. Case – (L & R coronary fistulas appeared to share a common ampulla)

14. Amplatzer Vascular Plug (AVP) (AGA Medical Corp
Amplatzer Vascular Plug (AVP) (AGA Medical Corp., Golden Valley, Minnesota, USA)
Designed for treatment of A-V fistulas and other malformation of the peripheral vasculature
Nitinol Mesh
Self expanding
Diameter sizes 2-16mm
Length 7-8 mm
Preloaded and attached to delivery cable (135 cm)
Delivered through standard 5-8F coronary guiding catheter

15. Case – LHC (2nd catheter in PA)

16. Case – Amplatzer Vascular Plug

17. Case AR1 guiding catheter through the RFV
Angiographic measurements revealed an ampulla with a diameter of 11mm and neck of 7mm
12 mm AVP device was placed
Heparin was reversed with protamine

18. Final Results

19. Final Results

20. Final Results

21. Summary
Elective closure of coronary artery fistulas is recommended in most patients due to risk of complications with advancing age
Amplatzer Vascular Plug is an easy and safe alternative to surgery or coil embolization