An Interventional Percutaneous Approach of Posttraumatic Left Coronary Artery Fistula Repair

Abstract: We present an interesting case on the management of a traumatic coronary artery fistula in a 39-year-old man who was stabbed by his wife. During emergency sternotomy, left lung and right ventricle injuries were repaired. On the second postoperative day, an acute myocardial infarction of the anterior wall was recognized. Coronary angiography revealed a rare case of a fistula between the left anterior descending coronary artery and the right ventricle of the heart, which was treated by a stent-graft to avoid a re-operation. 

J INVASIVE CARDIOL 2012;24(9):E207-E208

Key words: stent-graft, LCA fistula

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Case Report. A 39-year-old, unconscious man was admitted to our hospital suffering a stab wound to the 4th left intercostal space of the thorax complicated by combined hypovolemic and cardiogenic shock, blood pressure (BP) of 60/40 mm Hg, and heart rate (HR) of 140 beats/min on dopamine infusion 15 mkg x kg-1 x min-1. Bedside echocardiography showed pericardial effusion with signs of tamponade. The patient was urgently transported to the operating room, simultaneously receiving rapid 1000 mL 6% HAES infusion. After median sternotomy, bleeding from a 15-mm wide penetrating right ventricle wound in approximation of intervenricular groove at the region of the right ventricular outflow tract (RVOT) was stopped by Prolene 5.0 suture. Left pneumothorax and pericardial tamponade were decompressed, and 1500 mL of blood and thrombi were evacuated. After surgical operation and transfusion of 3 IU of erythrocyte mass and 2 IU of plasma, the patient improved and remained asymptomatic with BP of 120/80 mm Hg and HR of 105 beats/min. Ten hours after operation, the patient was extubated in the Cardiac Care Unit.

Two days after the index event, subsequent ST elevation +4.0 mV in leads V3-V4 and troponin level of 8.1 ng/mL was observed with no angina symptoms. Transthoracic echocardiography documented akinesia of the left ventricular apical segments, middle segments of anterior wall, and intraventricle septum. Pathological blood flow along the left anterior descending (LAD) directed to the right chamber was also observed (Figures 1A and 1B). Diagnostic angiography identified a fistula from the left coronary artery (LCA) descending to the right ventricle (LAD-RV) with a steal phenomenon and TIMI 2 flow (Figure 2A). LAD-RV shunt was successfully sealed by a 26 mm polytetrafluoroethylene-coated stent graft. Procedure effect was optimal, with TIMI 3 flow (Figures 2B and 2C). The patient was discharged on the 25th day of hospitalization with no clinical evidence of RV failure or angina symptoms.

Four months after index event, the patient was again admitted to our emergency department with recurrent angina symptoms. An urgent coronary angiography revealed an in-stent total occlusion of the LAD, which was promptly restored with implantation of a 3.0 x 32 mm paclitaxel-eluting stent (Figures 2D and 2E). No significant restenosis was observed at 24-month follow-up angiography (Figure 2F).

Discussion. Coronary fistula is defined as an abnormal communication between a coronary artery and cardiac chamber or major vessel or other structure, bypassing the myocardial capillary network.¹ The prevalence of posttraumatic LAD-RV fistula remains extremely rare.^2,3 However, the diagnosis in clinical practice is substantial due to the risk of heart failure, endocarditis, myocardial infarction, or arrhythmias.⁴ Data on percutaneous repair of posttraumatic fistulas are lacking.

The first report of a successful surgical repair of posttraumatic coronary artery fistula was performed in 1960. Conservative treatment of coronary artery fistulas in asymptomatic patients may result in complications such as angina and congestive heart failure.⁵ The majority of patients with symptomatic posttraumatic coronary artery fistula to ventricle require urgent surgical intervention by external obliteration or direct repair from the chamber.^6,7 However, a percutaneous closure of coronary artery fistulas was reported as an alternative method to surgery.¹

Conclusion

In the presented case, we reported for the first time an interventional percutaneous approach using a polytetrafluoroethylene-coated stent graft to seal the posttraumatic LAD-RV fistula. This management was performed to avoid reoperation in a young adult. Instead of restenosis, the long-term follow-up revealed convincing effect.

References

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2. Reyes LH, Mattox LK, Gaasch WH, Espada R, Beall AC Jr. Traumatic coronary artery-right heart fistula. Report of case and review of the literature. J Thorac Cardiovasc Surg. 1975;70(1):52-56. 
3. Renzulli A, Wren C, Hilton CJ. Coronary artery-left ventricular fistula and multiple ventricular septal defects due to blunt chest trauma. Thorax. 1989;44(12):1055-1056.
4. Gowda RM, Vasavada BC, Khan IA. Coronary artery fistulas: clinical and therapeutic considerations. Int J Cardiol. 2006;107(1):7-10.
5. Kirklin JW, Barratt-Boyes BG (eds). Cardiac Surgery. Chichester, United Kingdom: John Wiley & Sons, 1986:1387-1392.
6. Hancock Friesen C, Howlett JG, Ross DB. Traumatic coronary artery fistula management. Ann Thorac Surg. 2000;69(6):1973-1982.
7. Jones RC, Jahnke EJ. Coronary artery-atrioventricular fistula and ventricular septal defect due to penetrating wound of the heart. Circulation. 1965;32(6):995-1000.

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From the ¹First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland and ²Cardiovascular Center Cardiology, University Hospital of Zürich, Zürich, Switzerland.
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.
Manuscript submitted February 22, 2012 and accepted April 16, 2012.
Address for correspondence: Milosz J. Jaguszewski, MD, Cardiovascular Center, University Hospital Zuerich, Rämistrasse 100, 8091 Zürich, Switzerland. Email: milosz.jaguszewski@usz.ch