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Complex Case Intervention
Late-Presenting Left Internal Mammary to Great Cardiac Vein Fistula Treated with a Vascular Plug
October 2010
ABSTRACT: A 73-year old patient, who underwent triple bypass surgery in another hospital in 1991 after suffering an acute myocardial infarction, was admitted to our institution after an episode of unstable angina. Evidence of a left internal mammary artery grafted to the great cardiac anterior interventricular vein (GCV), with Qp:Qs > 1.5:1, was demonstrated by angiography. We report the closure of said fistula using a percutaneous left radial artery access and the deployment of an Amplatzer vascular occlusion device via the antegrade approach.
J INVASIVE CARDIOL
2010;22:E201–E203
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Acquired aorto-coronary venous fistulae (ACF), caused by inadvertent or late-developing anastomosis of an arterial conduit to a cardiac vein, are a rare but potentially serious complication of coronary artery bypass (CABG) surgery.1–5 Patients with ACF may remain asymptomatic or may present symptoms related either to ischemia (because the graft is unable to supply blood to the myocardium irrigated by the stenosed artery) or to a significant left to right shunt.6,7 Surgical repair has been recommended in symptomatic patients regardless of shunt ratio,8 although successful percutaneous corrective techniques have also been reported.1,2,4,8–10
Case Report. A 73-year old man with a significant medical history of diabetes mellitus, hypertension and dyslipidemia underwent CABG surgery in 1991 in another hospital after suffering an inferior lead acute myocardial infarction (AMI) with two-vessel disease in coronary angiography [95% stenosis of mid left anterior descending artery (LAD), 90% stenosis in the origin of the second diagonal branch (D2), and proximal occlusion of right coronary artery (RCA)]. In the surgical intervention the LIMA was anastomosed to the LAD and two aorto-coronary saphenous vein grafts (SVG) were anastomosed to D2 and to the posterolateral branch of the RCA. After coronary surgery the patient remained asymptomatic until May 2008, when he started to suffer symptoms compatible with effort angina. However, the patient did not seek medical attention until August 2008 when he suffered from a prolonged episode of chest pain at rest. ECG on admission showed Q waves in the inferior leads and R wave amputation in the anteroseptal leads. The maximum troponin I measured was 8.07 ng/mL. After the diagnosis of NSTEMI, the patient underwent a transthoracic echocardiogram, which showed a non dilated left ventricle (LV) with moderately depressed systolic function due to hypokinesia of the inferolateral walls, mild dilated right ventricle (RV) with normal function, mild pulmonary hypertension (systolic pressure of pulmonary artery of 49 mmHg), and a dilated coronary sinus (12 mm of diameter). Angiography showed three vessel coronary artery disease (99% stenosis of mid LAD and occlusion of D2 in its origin, 99% of proximal left circumflex artery [LCX], and occlusion of the proximal RCA) (Figures 1A and 1B). Angiography of the grafts showed a patent SVG to D2, an occlusion of SVG to the posterolateral branch of the RCA in its origin and a LIMA-GCV anastomosis with marked filling of the coronary sinus through GCV (Figures 2A and 2B). A significant arteriovenous shunt was detected during the cardiac catheterization (Qp/Qs = 1.7). After an interdisciplinary team meeting including cardiac surgeons, interventional cardiologists and clinical cardiologists, it was decided to proceed by treating percutaneosly the medial stenosis of the LAD and the proximal lesion of the LCX (optimal angiographic result, Figure 3) and attempting closure of the ACF in a separate procedure to avoid contrast media-associated nephropathy. Procedure. Through a left radial access, a 6 Fr internal mammary guide catheter was engaged in the ostium of the LIMA, and a 0.014″ Whisper Extra-Support coronary wire (Abbott Vascular, Abbott Park, Illinois) was advanced to the distal portion of the graft. Thereafter, a Maverick® catheter balloon – 5.5 x 20 mm (Boston Scientific, Natick, Massachusetts) was inflated in the mid portion of the artery and used for deep intubation of the guide to increase catheter support. Subsequently, an Amplatzer Vascular Plug Occluder II 8 mm (AGA Medical Corporation, Plymouth, Minnesota) was successfully deployed (Figure 3), and the occlusion of the vessel was accomplished. Device diameter was selected to achieve a diameter 30% larger than the vessel at the occlusion site. After the procedure, a selective injection into the LIMA showed no contrast flow between the LIMA and the GCV (Figure 4). Qp/Qs measured after the closure was 1.07, thus excluding other potential sources of intracardiac shunts. The post-procedural course was uneventful and the patient was discharged the next day. Discussion. ACF is an infrequent complication of CABG surgery. The majority of cases reported in the scientific literature are fistulae created between SVG and the GCV, but few cases of anastomosis between LIMA and GCV have been published.1 Although infrequent, however, some factors (i.e., coronary artery intramyocardial course, presence of overlaying epicardial fat, pericardial disease leading to fibrosis and scarring of the artery, sclerosed veins, and the use of cardioplegia) may lead to confusion between a GVC and a coronary artery.11 Moreover, fistulae may develop several years after surgery, the so-called late-developing fistulae, described in cases of communications between LIMA grafts and the pulmonary circulation.12 These ACF may appear as a result of unclipped side branches of LIMA that could result in recanalization into the pulmonary artery or the lung parenchyma or due to inflammation processes near the graft. Clinical presentation of this condition is often recurrence of anginal symptoms, development of heart failure or the presence of a continuous murmur on physical examination. Fistulae produced by inadvertent anastomosis during surgery typically present a few months after the procedure, although some reports have addressed the possibility of late presentation, years after the operation.6 On the other hand, late-developing fistulas become clinically apparent several years after surgery. In our case, the late presentation,17 years after surgery, may point to a late-developing fistula, although an inadvertent anastomosis during the CABG cannot be definitely excluded. The patient’s symptoms or, less frequently, the consequences of a significant shunt determine the treatment option. Traditionally, fistula ligation or a redo CABG are the elective treatments in clinically significant fistulae.3,13 However, in iatrogenic ACF few cases of occlusion using coil embolization, a detachable balloon or covered stent deployment have been published.1,2,4,8–10 Many case reports have shown the safety and feasibility of the percutaneous approach in congenital fistulae using Amplatzer vascular occluders13 and Amplatzer vascular plugs have been used as well in a myriad of vascular procedures confirming the safety and feasibility of these devices.14 Specifically, the Amplatzer Vascular Plug Occluder II with its multi-segmented, multi-layered design significantly reduces the time to occlusion for transcatheter embolization procedures. To the best of our knowledge, this report is the first to describe the treatment of a late ACF of the LIMA graft to the GCV using a percutaneous radial approach and the deployment of a closure device. The decision to attempt the percutaneous treatment of the ACF and coronary lesions was made taking into account the patient’s age and surgical risk, the need for a second intervention (that could jeopardize the other grafts) and the necessity of fistula embolization due to a high shunt fraction. The comfort and safety of the radial access, the use of a more physiological antegrade approach avoiding the coronary sinus route and its infrequent albeit harmful consequences,15 and the feasibility of vascular device occluders made us select this treatment strategy. As we can observe in the figures, the target vessel was easily engaged with the guide and wire and very early after the device deployment the fistula was completely closed and the shunt fraction returned to normal. In conclusion, our report shows a successful occlusion of ACF from LIMA to GCV using an Amplatzer vascular plug occluder, which is technically less demanding, safer, and requires shorter procedure time compared to surgery and other percutaneous approaches.
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From the Interventional Cardiology Unit, Division of Cardiology. Complejo Hospitalario Universitario A Coruña, A Coruña, Spain.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted January 29, 2010, provisional acceptance given February 2, 2010, final version accepted February 19, 2010.
Address for correspondence: Rodrigo Estevez-Loureiro, MD, Division of Cardiology, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain. E-mail: Rodrigo.Estevez.Loureiro@sergas.es
Case Report. A 73-year old man with a significant medical history of diabetes mellitus, hypertension and dyslipidemia underwent CABG surgery in 1991 in another hospital after suffering an inferior lead acute myocardial infarction (AMI) with two-vessel disease in coronary angiography [95% stenosis of mid left anterior descending artery (LAD), 90% stenosis in the origin of the second diagonal branch (D2), and proximal occlusion of right coronary artery (RCA)]. In the surgical intervention the LIMA was anastomosed to the LAD and two aorto-coronary saphenous vein grafts (SVG) were anastomosed to D2 and to the posterolateral branch of the RCA. After coronary surgery the patient remained asymptomatic until May 2008, when he started to suffer symptoms compatible with effort angina. However, the patient did not seek medical attention until August 2008 when he suffered from a prolonged episode of chest pain at rest. ECG on admission showed Q waves in the inferior leads and R wave amputation in the anteroseptal leads. The maximum troponin I measured was 8.07 ng/mL. After the diagnosis of NSTEMI, the patient underwent a transthoracic echocardiogram, which showed a non dilated left ventricle (LV) with moderately depressed systolic function due to hypokinesia of the inferolateral walls, mild dilated right ventricle (RV) with normal function, mild pulmonary hypertension (systolic pressure of pulmonary artery of 49 mmHg), and a dilated coronary sinus (12 mm of diameter). Angiography showed three vessel coronary artery disease (99% stenosis of mid LAD and occlusion of D2 in its origin, 99% of proximal left circumflex artery [LCX], and occlusion of the proximal RCA) (Figures 1A and 1B). Angiography of the grafts showed a patent SVG to D2, an occlusion of SVG to the posterolateral branch of the RCA in its origin and a LIMA-GCV anastomosis with marked filling of the coronary sinus through GCV (Figures 2A and 2B). A significant arteriovenous shunt was detected during the cardiac catheterization (Qp/Qs = 1.7). After an interdisciplinary team meeting including cardiac surgeons, interventional cardiologists and clinical cardiologists, it was decided to proceed by treating percutaneosly the medial stenosis of the LAD and the proximal lesion of the LCX (optimal angiographic result, Figure 3) and attempting closure of the ACF in a separate procedure to avoid contrast media-associated nephropathy. Procedure. Through a left radial access, a 6 Fr internal mammary guide catheter was engaged in the ostium of the LIMA, and a 0.014″ Whisper Extra-Support coronary wire (Abbott Vascular, Abbott Park, Illinois) was advanced to the distal portion of the graft. Thereafter, a Maverick® catheter balloon – 5.5 x 20 mm (Boston Scientific, Natick, Massachusetts) was inflated in the mid portion of the artery and used for deep intubation of the guide to increase catheter support. Subsequently, an Amplatzer Vascular Plug Occluder II 8 mm (AGA Medical Corporation, Plymouth, Minnesota) was successfully deployed (Figure 3), and the occlusion of the vessel was accomplished. Device diameter was selected to achieve a diameter 30% larger than the vessel at the occlusion site. After the procedure, a selective injection into the LIMA showed no contrast flow between the LIMA and the GCV (Figure 4). Qp/Qs measured after the closure was 1.07, thus excluding other potential sources of intracardiac shunts. The post-procedural course was uneventful and the patient was discharged the next day. Discussion. ACF is an infrequent complication of CABG surgery. The majority of cases reported in the scientific literature are fistulae created between SVG and the GCV, but few cases of anastomosis between LIMA and GCV have been published.1 Although infrequent, however, some factors (i.e., coronary artery intramyocardial course, presence of overlaying epicardial fat, pericardial disease leading to fibrosis and scarring of the artery, sclerosed veins, and the use of cardioplegia) may lead to confusion between a GVC and a coronary artery.11 Moreover, fistulae may develop several years after surgery, the so-called late-developing fistulae, described in cases of communications between LIMA grafts and the pulmonary circulation.12 These ACF may appear as a result of unclipped side branches of LIMA that could result in recanalization into the pulmonary artery or the lung parenchyma or due to inflammation processes near the graft. Clinical presentation of this condition is often recurrence of anginal symptoms, development of heart failure or the presence of a continuous murmur on physical examination. Fistulae produced by inadvertent anastomosis during surgery typically present a few months after the procedure, although some reports have addressed the possibility of late presentation, years after the operation.6 On the other hand, late-developing fistulas become clinically apparent several years after surgery. In our case, the late presentation,17 years after surgery, may point to a late-developing fistula, although an inadvertent anastomosis during the CABG cannot be definitely excluded. The patient’s symptoms or, less frequently, the consequences of a significant shunt determine the treatment option. Traditionally, fistula ligation or a redo CABG are the elective treatments in clinically significant fistulae.3,13 However, in iatrogenic ACF few cases of occlusion using coil embolization, a detachable balloon or covered stent deployment have been published.1,2,4,8–10 Many case reports have shown the safety and feasibility of the percutaneous approach in congenital fistulae using Amplatzer vascular occluders13 and Amplatzer vascular plugs have been used as well in a myriad of vascular procedures confirming the safety and feasibility of these devices.14 Specifically, the Amplatzer Vascular Plug Occluder II with its multi-segmented, multi-layered design significantly reduces the time to occlusion for transcatheter embolization procedures. To the best of our knowledge, this report is the first to describe the treatment of a late ACF of the LIMA graft to the GCV using a percutaneous radial approach and the deployment of a closure device. The decision to attempt the percutaneous treatment of the ACF and coronary lesions was made taking into account the patient’s age and surgical risk, the need for a second intervention (that could jeopardize the other grafts) and the necessity of fistula embolization due to a high shunt fraction. The comfort and safety of the radial access, the use of a more physiological antegrade approach avoiding the coronary sinus route and its infrequent albeit harmful consequences,15 and the feasibility of vascular device occluders made us select this treatment strategy. As we can observe in the figures, the target vessel was easily engaged with the guide and wire and very early after the device deployment the fistula was completely closed and the shunt fraction returned to normal. In conclusion, our report shows a successful occlusion of ACF from LIMA to GCV using an Amplatzer vascular plug occluder, which is technically less demanding, safer, and requires shorter procedure time compared to surgery and other percutaneous approaches.
References
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