ADVERTISEMENT
Transcatheter Closure of a Coronary Artery to Pulmonary Artery Fistula With Two Sequential Giant Aneurysms
© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.
A 73-year-old female presented with exertional dyspnea and was found to have a coronary artery to pulmonary artery (PA) fistula with 2 sequential giant aneurysms. Her chest radiograph (Figure, A) showed a mass (#) above the cardiac silhouette. Computed tomography (CT) coronary angiogram (Figure, B) with 3-dimensional reconstruction (Figure, C) identified a coronary artery to PA fistula arising from a septal branch of the left anterior descending artery (LAD) draining into the main pulmonary trunk. The fistula was large with 2 sequential giant aneurysms (* and †) before draining into the PA. A coronary angiogram (Figure, D; Video 1) confirmed the presence of the fistula with the 2 giant aneurysms and no significant coronary artery stenoses.
Due to persistent symptoms and being deemed a poor surgical candidate by the heart team, transcatheter closure was planned with a strategy using endovascular coils to embolize both the feeder from the proximal LAD and the outlet at the PA. The left coronary artery was engaged with a 6-French XB 3.5 guide catheter, and the septal feeder artery was first wired with a 0.014-inch guidewire and microcatheter support. The proximal aneurysm, followed by the distal aneurysm, were then wired. Wiring of the fistula outflow to the PA via the antegrade approach was not successful, and thus a retrograde transvenous approach through the pulmonary artery was attempted; this was also unsuccessful. Coil embolization of the 2 giant aneurysms was then performed using 34 Medtronic Concerto Helix coils (sixteen 20 x 50-mm, seven 18 x 40-mm, seven 16 x 40-mm, and four 14 x 30-mm coils). The septal artery feeder was coiled with 5 Medtronic Concerto coils (one 8 x 30-mm, one 6 x 20-mm, two 4 x 8-mm, and one 3 x 8-mm coils) (Figure, E, F; Video 2). At 6-month follow-up, the patient reported improvement in her breathlessness and a repeat CT coronary angiogram (Figure, G) showed reduction in the size of the aneurysm with no evidence of flow across the fistula.
Affiliations and Disclosures
From the 1Changi General Hospital, Singapore; 2National Heart Centre Singapore, Singapore; 3Singapore General Hospital, Singapore; 4Duke-NUS Medical School, Singapore.
Disclosures: Dr Yap has received speaker's honorarium from Abbott, Biosensors, Biotronik, Boston Scientific, Edwards, GE healthcare, J&J, Kaneka, Medtronic, and Terumo. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.
Address for correspondence: Jonathan Yap, MBBS, MRCP, MPH, National Heart Centre Singapore, 5 Hospital Dr, Singapore 169609. Email: jonyap@yahoo.com; X: @jonyap88
