Transbrachial Coil Embolization of a Giant Coronary Artery Fistula

Abstract: Coronary artery fistulae can present late in adult life. We describe the case of a 71-year-old woman who developed a right coronary fistula, which was managed by percutaneous transbrachial coil embolization. Complete closure of the fistula was confirmed by follow-up angiography at 10 months. 

J INVASIVE CARDIOL 2012;24(8):E159-E160

Key words: coronary artery fistula, coil embolization, congenital heart disease in adults

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Case Report

A 71-year-old woman visited our hospital because of chest pain. Routine examination revealed a continuous murmur on the lower left sternal edge. Chest x-ray was negative. Electrocardiogram showed a negative T-wave at II, III, and aVF leads. Transthoracic echocardiography revealed an echo-free space on the right side of the right ventricle and color flow from the right coronary artery (RCA) to the echo-free space. There was no other cardiac structural abnormality. Computed tomography revealed right coronary dilatation and a giant fistula (6 × 6 × 12 cm). The fistula drained into the coronary sinus (Figure 1).

The patient subsequently underwent cardiac catheterization. Right-sided pressures were normal, demonstrating a shunt at the atrial level with a calculated Qp:Qs of 1.4:1, which indicated that this shunt was of moderate severity. Coronary angiography demonstrated that the left coronary artery was normal, but the RCA showed severe dilatation and confirmed the presence of the giant fistula (Figure 2).

Treatment strategies were discussed with the patient and cardiac surgeons. Since the patient was extremely reluctant to undergo surgical closure, the percutaneous approach was chosen.

The procedure was carried out under local anesthesia with sedation and a 6 Fr sheath was inserted in the right brachial artery. A 4.5 Fr straight guiding catheter (Cokatte; Asahi Intec Corporation) was used to enter the right coronary ostium, and was deeply engaged to access the mid RCA. IDC embolization coils (14 x 18 mm, 8 x 18 mm, and 7 x 18 mm; Boston Scientific, Inc) and Diamond embolization coils (2 x 6 mm, 2 x 5 mm, and 2 x 4 mm; Boston Scientific, Inc) were delivered to the distal vessel via a micro catheter (Renegrade; Boston Scientific, Inc). Care was taken to avoid the lumen of the posterior descending artery. This resulted in the occlusion of the fistulous communication and the posterior descending artery was confirmed to have excellent flow. The patient’s hemodynamics remained stable during the procedure, and there were no electrocardiographic changes indicative of myocardial ischemia. Cardiac enzymes remained at normal levels after the procedure. The patient reported resolution of her symptoms, and was discharged on the following day. The follow-up coronary angiography performed at 10 months confirmed complete closure of the RCA fistula (Figure 3). Subsequent echocardiography and computed tomography also confirmed that the fistula was no longer present.

Discussion

Anomalies of the coronary arteries are uncommon. They are detected incidentally in approximately 1% of patients undergoing angiography for the investigation of suspected obstructive coronary heart disease.^1,2 Congenital coronary arteriovenous coronary fistula is a rare direct communication between a coronary artery and one of the cardiac chambers, the coronary sinus, the superior vena cava, or the pulmonary artery. Congenital coronary arteriovenous fistula constitutes 0.87% of all coronary artery anomalies³ and is the most common hemodynamically significant coronary artery anomaly. The most common origin of a coronary fistula is the RCA, accounting for 50%-60% of the cases. Our patient had a large fistula between the RCA and the right coronary sinus. Several cases of a giant coronary artery fistula have been reported; pathologic examination showed marked thinning of the media and mucoid degeneration, resulting in an increase of the vessel.⁴ Congenital coronary arteriovenous fistulae are usually diagnosed in children as an incidental finding on an echocardiogram or when investigating cardiac symptoms or a continuous murmur. They are also diagnosed by chance in adults. One recent review found that chest pain and dyspnea are the presenting symptoms in 71% of adult cases, while 79% of pediatric cases are asymptomatic.⁵ The usual cause of chest pain is purported to be a coronary steal phenomenon, which could be persistent or episodic. This patient had symptoms suggestive of episodic steal, where physical exertion results in increased flow through the fistula and compromises coronary perfusion.

The therapeutic options are transcatheter closure and cardiac surgery. The transcatheter intervention is less invasive and was preferred by our patient. Transcatheter closure can be achieved by using coils, balloons, a patent duct occluder, Amplatzer occluders, etc.^6-8 Coil embolization is very easy, safe, and less invasive than other methods. Surgical closure is done under direct visualization and there is evidence of successful long outcomes, but it is an invasive procedure.⁹ In our patient, percutaneous closure produced long-term results. Percutaneous management of coronary artery fistulae yields a high degree of procedural success with a very low risk of serious complications.¹⁰ Current data from 45 patients who underwent transcatheter closure of fistulae showed that 91% of these patients presented with complete closure at the follow-up imaging, and 93% remained free of symptoms and complications.¹¹ A review article found a procedural mortality rate of 2.2% with the coil technique compared with 1.4% perioperative mortality from surgical closure. Our patient complained of chest pain and she did not have atherosclerotic coronary artery disease; thus, we decided to perform percutaneous transcatheter closure of the coronary artery fistula.

There have been only a few cases reported in which percutaneous transcatheterization was employed to close a coronary artery fistula.^12,13 However, these reports utilized the transfemoral approach, while we selected the transbrachial approach for our patient. The transbrachial approach is less invasive — patients can even work after the procedure and their quality of life is preserved. Our patient had a very long RCA due to coronary anomalies, and computed tomography revealed that the large French size catheter used via the transfemoral approach to enter the right coronary ostium would not be useful to deliver the microcatheter and coils to the distal segment of RCA. Therefore, we tried deep engagement of the RCA with a small (4.5) French size Cokatte catheter, which has excellent flexibility and conformability.

Long-term complications of percutaneous coil embolization include coronary thrombosis, myocardial infarction, and cardiomyopathy. Clinical predictors of failure are advanced age at diagnosis, tabacco use, diabetes, systemic hypertension, and dyslipidemia.^14,15 Failure of closure may result in recanalization, collateral flow, and neovascularization. These appear within 6 to 12 months.¹⁶ Armsby et al found that only 9% of patients had a residual fistula at a mean follow-up of 1 year after transcatheter closure.¹¹ Recurrence has been reported after successful surgery as well, with rates varying between 16%-22%.¹⁷ In our patient, coil embolization of the fistula proved successful at the angiography performed 10 months after the procedure.

Conclusion

With this case we have demonstrated that a giant coronary fistula can be closed by coil embolization following the transbrachial approach and using a small-sized catheter.

References

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From the ¹Department of Cardiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya City, Saitama, Japan and the ²Department of Radiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya City, Saitama, Japan.
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 October 28, 2011, provisional acceptance given November 7, 2011, final version accepted November 10, 2011.
Address for correspondence: Takaaki Komatsu, MD, 2-1-50 Minami-Koshigaya, Koshigaya City, Saitama, Japan. Email: takaaki_km2@yahoo.co.jp