2021 Scientific Sessions

Title:
Percutaneous Closure of an Iatrogenic Coronary Artery Fistula with a Covered Stent Using A Primary Retrograde Crossing Strategy

Introduction:
Iatrogenic coronary artery fistulas (CAFs) are a rare complication of percutaneous coronary intervention. Current guidelines recommend closure of all large CAFs and select small to medium sized CAFs when accompanied by imaging or electrical abnormalities or symptoms. Closure with transcatheter techniques can present technical challenges with difficulty wiring across large defects as well as limited use of endovascular coils due to the risk of embolization.

Clinical Case:
A 63 year old woman with a history of coronary artery disease status post two vessel CABG (SVG-OM, SVG-RPDA), mitral regurgitation status post mitral valve repair, diabetes mellitus, and tobacco use presented with CCS class IV angina despite maximally tolerated anti-anginal medications. Previous angiography demonstrated occluded vein grafts and a chronic total occlusion of the proximal RCA.

Given uncontrolled angina despite medical optimization, she underwent chronic total occlusion percutaneous coronary intervention of the right coronary artery. A primary retrograde approach via LAD septal and left circumflex epicardial collaterals was unsuccessful due to inability to cross due to tortuosity. Antegrade dissection reentry with the Stingray balloon was performed with re-entry into the right posterior AV groove branch. The right posterior descending artery was accessed with a sub-intimal tracking and reentry technique. Balloon angioplasty of the RPDA and RPAV branches was complicated by an Ellis III CS perforation with fistula formation between the right coronary artery and right atrium as well as an intramyocardial hematoma. Following prolonged balloon inflation proximal to the fistula, the defect appeared stable and the procedure was completed with stenting of the proximal and mid RCA.

One week after discharge, the patient presented to the emergency department with recurrent angina and shortness of breath. Diagnostic angiogram was notable for a large CAF. The patient returned two months later for elective percutaneous closure of the CAF. Given the size of the defect and anatomic ambiguity of the distal vessel reconstitution, the decision was made to cross the defect in a primary retrograde fashion. Via septal collaterals from the LAD, the defect was crossed with a Mongo wire and Caravel microcatheter. Following wire externalization, IVUS demonstrated a relatively short defect in the distal right coronary artery. A 3.0 x 26 mm PK Papyrus covered stent was deployed at 12 atmospheres from the posterior descending artery into the distal right coronary artery, eliminating antegrade flow into the fistula and right posterior AV groove branch. Final angiography demonstrated complete resolution of the fistulous connection. Following the procedure, patient reported resolution of angina which has persisted six months after the procedure.

Discussion:
This case highlights a rare complication of percutaneous coronary intervention and the use of retrograde coronary wiring to seal a CAF with a covered stent. Retrograde wiring is an effective method for solving anatomic ambiguity and facilitated imaging guided stenting. By using techniques traditionally reserved for the treatment of chronic total occlusions, the CAF was successfully percutaneously treated.