Coil embolization of a complex single-confluence coronary-to-pulmonary artery fistula
Presenter
Teodora Donisan, MD, Mayo Clinic College of Medicine and Science, Rochester, MN
Teodora Donisan, MD1, Emily Cendrowski, MD2, Devika Kir, MBBS3, Jason Howard Anderson, M.D., FSCAI4 and Rajiv Gulati, M.D. Ph.D., FSCAI1, (1)Mayo Clinic College of Medicine and Science, Rochester, MN, (2)The University of Arizona, Tucson, AZ, (3)Mayo Clinic, Rochester, MN, Rochester, MN, (4)Mayo Clinic, Rochester, MN
Title
Coil embolization of a complex single-confluence coronary-pulmonary artery fistula
Introduction
Coronary-pulmonary artery fistula (CPAF) is a rare congenital coronary anomaly. CPAFs may be identified incidentally or manifest with symptomatic limitation due to left-to-right shunting and associated steal-ischemia. Indications for closure are primarily based on the presence of symptoms including myocardial ischemia, arrhythmia, ventricular dysfunction, and endarteritis. Herein, we demonstrate a case where objective criteria led many to recommend against closure with the presence of a large fistula confirmed intra-operatively.
Clinical Case
A 38-year-old competitive athlete presented with exertional angina and dyspnea. Coronary computed tomography angiography revealed a complex coronary-pulmonary artery fistula. Rest and exercise right heart catheterization demonstrated normal filling pressures and cardiac output, without significant left-to-right shunting via Fick assessment (limitations of streaming and improper mixing noted). Coronary angiography confirmed multiple fistulous connections and anomalous vessels arising from left anterior descending (LAD) artery septals, right coronary artery marginals, and the right aortic sinus. These vessels terminated via a single egress to the main pulmonary artery (PA) consistent with persistence of the normal involuting branch from the pulmonary sinus. Given the duration of symptoms in the absence of an alternative etiology and dilation of the LAD consistent with remodeling, the patient elected to undergo endovascular embolization of the fistula.
Pre-procedural planning included two strategies: antegrade via anomalous connections to small, serpiginous collaterals, or retrograde from the PA egress. Given the angle to enter retrograde appeared unfavorable, an antegrade approach was utilized. Bilateral femoral artery access was obtained to allow for right and left circulation imaging. Utilizing an XB guide, guideliner, turnpike LP microcatheter and Suoh-03 wire, a course from the left coronary artery to main PA via the fistula was established. Embolization required implantation of a POD5 Ruby coil given the size of the fistula trunk entering the PA and high flow state. A 60 cm packing coil was utilized subsequently to ensure full occlusion with no extension into the normal branch segments. Following closure, the patient demonstrated transient hypotension. Transthoracic echocardiogram, coronary angiography, and neurologic examination were performed and unremarkable. Given no evidence of an underlying etiology, we presume the abrupt decrease in shunt volume altered left sided preload and cardiac output until the patient compensated in the setting of general anesthesia. The patient recovered well post-procedure and was discharged home the following day.
Discussion
This case represents a diagnostic dilemma on the management of CPAF. The patient had received multiple opinions on whether treatment was indicated, both for and against. The presence of normal exercise hemodynamics was often cited as the indication to avoid intervention; however, the size of the fistula intra-operatively was large with evidence of coronary remodeling present. Although the most common treatment has been surgical ligation, transcatheter fistula closure may see a potentially increasing role as a less invasive approach especially as new coronary tools and new coil technology allows for safe closure in large diameter and high flow vessels.