The Diagonal Branch to the Accompanying Vein Fistula After Rotational Atherectomy

J INVASIVE CARDIOL 2019;31(11):E335-E336.

Key words: complications, rotational atherectomy

Rotational atherectomy (RA) was developed to facilitate percutaneous treatment of severely calcified coronary lesions. Common RA complications include vagus reflex, perforation, no reflow, coronary spasm, and lateral branch occlusion. Coronary arteriovenous (AV) fistula is a rare complication of percutaneous coronary intervention (PCI); AV fistula originating from the left anterior descending (LAD) coronary artery and draining into the great cardiac vein as a result of RA in a complex calcified lesion complicated by cardiac failure has been reported. We report a case of RA-induced fistula between the diagonal branch and the accompanying vein.

A 67-year-old man with a history of hypertension and gastritis presented to our institution with unstable angina. Coronary angiography demonstrated diffuse calcified 80%-90% stenosis in the LAD and diagonal branch bifurcation (Figure A; Video 1). The patient was referred for RA. In order to avoid occlusion of the side branch, RA was also planned in the diagonal branch. RA was performed in the LAD with a 1.5 mm burr (Boston Scientific) at 160,000 rpm for a total of 40 seconds (Figure B; Video B) and in the first diagonal using the same 1.5 mm burr at 160,000 rpm for a total of 30 seconds (Figure C; Video C). This resulted in the formation of an AV fistula arising from the diagonal to the accompanying vein (Figure D; Video D). Echocardiography showed no pericardial effusion. The patient was asymptomatic and returned to the coronary care unit.

RA is a very effective treatment for calcified lesions. In a calcified side-branch vessel, RA can effectively prevent occlusion of the lateral branch. Coronary AV fistula is a rare complication of PCI. It can originate from any of the major coronary arteries and drain into the coronary sinus, the great cardiac vein, and the right ventricle. The AV fistula in the present case occurred during RA to the diagonal branch. To our knowledge, this is the first case of AV fistula from the side branches to the accompanying vein as a complication of RA. Since the patient did not have any special symptoms, no special treatment was given. Coronary AV fistula can sometimes close by itself. If the fistula is large, it can cause coronary steal symptoms, which can be treated by spring coil or stent-graft implantation. We will closely follow the patient to decide the next treatment measures.

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From the ¹Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China; and ²Huangshi Central Hospital, Huangshi, Hubei, China.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted February 28, 2019.

Address for correspondence: Xiaobo Mao, MD, Department of Cardiology, Union Hospital, 1277 Jiefang Avenue, Wuhan, Hubei, China. Email: heart@vista.aero