Disclosure: Dr. Trayer and Dr. Varghese report no conflicts of interest regarding the content herein. Dr. George reports he is a consultant for Boston Scientific.

The authors can be contacted via Dr. Jon George at georgej@deborah.org.

His other comorbidities included sick sinus syndrome status post permanent pacemaker placement, dyslipidemia, and diabetes mellitus. The patient underwent cardiac catheterization and coronary angiography, which demonstrated a reduced ejection fraction of 20%, patent SVG to OM graft, patent mid LAD stent, proximal 90% right coronary artery (RCA) stenosis, and a coronary-cameral fistula from the right acute marginal branch (AM) to the right ventricle (RV) (Figure 1). The patient underwent percutaneous coronary intervention (PCI) with revascularization of the proximal RCA with a 2.25 x 12mm drug-eluting stent (DES) (Figure 2). Due to continued dyspnea on exertion, the patient underwent planned coil embolization of the right AM coronary cameral fistula to the RV.  

A 6 French internal mammary (IM) 90cm guide was used to selectively engage the RCA via right femoral artery access. Angiography demonstrated increased fistula flow since revascularization of the proximal RCA with stenting. A Prowater wire (Abbott) was advanced into the AM branch at the origin of the fistula. A 150cm CXI 0.018-inch support catheter (Cook) was advanced to the tip of the guidewire. The guidewire was then removed and two Interlock 2.0 x 4mm coils (Boston Scientific) were deployed within the terminal end of the AM branch to occlude the fistula (Figure 3). There was excellent final angiographic result with obliteration of flow into the fistula (Figure 4). The patient was monitored overnight and discharged home in stable condition. Upon follow-up, the patient reported complete resolution of his heart failure symptoms and shortness of breath.

Discussion

Coronary arterial fistulas (CAF) or malformations are connections between one or more of the coronary arteries, and a cardiac chamber or a great vessel. CAF are rare congenital anomalies with the exact incidence unknown. However, they comprise the most common hemodynamically significant coronary artery anomalies. Fistulas occurring from the RCA occur in about half the cases and over 90% of all fistulas drain to the right side of the heart.¹ The clinical features depend upon the size and location of these fistulas, and range from asymptomatic continuous murmurs to congestive heart failure. The potential complications related to untreated CAF include pulmonary hypertension and congestive heart failure with a large left-to-right shunt, bacterial endocarditis, rupture or thrombosis of the fistula, and myocardial ischemia distal to the fistula due to a myocardial steal.² Due to the morbidity of these potential complications, closure of these fistulas is sometimes advocated even in asymptomatic individuals.³ Untreated larger fistulas may even predispose the individual to premature coronary artery disease in the affected vessel.²  

Surgery has long been the accepted treatment of choice for fistula closure. Complications of surgery include myocardial infarction, arrhythmia, transient ischemic changes, and stroke.^4,6  Transcatheter closure of coronary arterial fistulas was first described by Reidy et al in 1983 using a detachable balloon.⁵  With the expanding role of percutaneous interventions, several studies have confirmed that transcatheter closure is feasible and embolization of CAF with coils has been well described in the literature.^7-13 The advantages of the transcatheter approach include decreased morbidity, lower cost, shorter recovery time, and avoidance of thoracotomy and cardiopulmonary bypass.¹³  Percutaneous transcatheter closures, when available, should now be considered the treatment of choice. However, transient electrocardiographic changes, arrhythmias, and fistula dissection are potential complications with coil embolization and transcatheter closure strategies.^4,12 Moreover, multiple coils may be needed to close large fistulas, which can increase fluoroscopy time, contrast load, and chances of failure to occlude the fistula. 

References

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