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Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature
Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature☆ Leire Unzué a,⁎, Eulogio García a, Belén Díaz-Antón b, Javier Fernández-Portales c, Rodrigo Teijeiro a, Miguel Rodríguez-del-Río d a
Interventional Cardiology, Hospital Universitario Madrid Montepríncipe, Madrid, Spain Cardiac Image Unit, Hospital Universitario Madrid Montepríncipe, Madrid, Spain Interventional Cardiology, Hospital San Pedro de Alcántara, Cáceres, Spain d Anesthesiology, Hospital Universitario Madrid Montepríncipe, Madrid, Spain b c
a r t i c l e
i n f o
Article history: Received 10 February 2017 Received in revised form 28 February 2017 Accepted 1 March 2017 Available online xxxx Keywords: Coronary artery fistulae Percutaneous closure Ductal occluder
a b s t r a c t Coronary artery fistulae (CAF) are uncommon heart defects defined as a communication between a coronary artery and a cardiac chamber or vascular structure. They are frequently asymptomatic; nevertheless, they can produce angina, dyspnea or cardiac failure. CAF are believed to be congenital; however, isolated cases of CAF have been described as rare complications of cardiac surgery. We report the percutaneous closure of a giant CAF in an adult patient with angina and previous pericardiectomy. © 2017 Elsevier Inc. All rights reserved.
Contents 1. 2. 3.
4.
Introduction . . . . . . . . . . . . . . . . . . . . . . Case report. . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . 3.1. CAF origin . . . . . . . . . . . . . . . . . . . . 3.2. CAF, to treat or not to treat: events during follow-up 3.3. Percutaneous approach: wire-maintaining technique 3.4. Device selection . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction Coronary artery fistulae (CAF) are uncommon heart defects defined as a communication between a coronary artery and a cardiac chamber or vascular structure [1]. They are frequently asymptomatic; nevertheless, they can produce angina, dyspnea or cardiac failure.
☆ Conflict of interest statement: The authors have no conflicts of interest to declare. ⁎ Corresponding author at: Hospital Universitario Madrid Montepríncipe, Interventional Cardiology Unit, Avda Montepríncipe 25, 28668, Boadilla del Monte, Madrid, Spain. Tel.: +34 917089900. E-mail address: [email protected] (L. Unzué).
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CAF are believed to be congenital; however, isolated cases of CAF have been described as rare complications of cardiac surgery [2,3]. We report the percutaneous closure of a giant CAF in an adult patient with angina and previous pericardiectomy. 2. Case report A 69-year-old woman with a three-month history of angina and minimal effort dyspnea was admitted for percutaneous closure of a left coronary circumflex (LCX) CAF. The patient had suffered a constrictive pericarditis 14 years before, with a normal coronary angiogram followed by a surgical pericardiectomy; and was under oral anticoagulant therapy with apixaban due to chronic atrial fibrillation. A right
http://dx.doi.org/10.1016/j.carrev.2017.03.002 1553-8389/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
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L. Unzué et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Fig. 1. (A) Coronary angiogram from the Aorta (Ao) showing the fistula with drainage in the right atrium (RA). (B) Advance of a hydrophilic wire through the fistulous vessel to the right atrium. (C) Arteriovenous loop reaching the inferior cava vein (ICV). (D) Selective angiography of the fistula from the aortic side.
catheterization ruled out significant constriction showing data concordant with high cardiac output (11l/min). The coronary angiogram performed in another center showed a big circumflex coronary artery, with a tortuous pathway and an independent drainage into the right atrium, through the coronary sinus (Fig. 1A). Given the high risk of a new surgical intervention (Euroscore II 4.7%), the patient's case was discussed in the Heart Team and a percutaneous closure of the coronary artery fistula was planned. Right femoral artery was canalized, advancing a multipurpose 6 French catheter to the left aortic coronary sinus, pushing a 0.35″hydrophilic Terumo wire through the tortuous pathway of the fistula, reaching the right atrium (Fig. 1B, Video 1). Given the need of an accurate support to advance the closure device, an arteriovenous loop was performed, canalizing the right femoral vein, to capture the wire in the right atrium with a 30 mm gooseneck, externalizing it through the venous access to establish the circuit (Fig. 1C). This maneuver allowed for the selective canalization of the fistula from the arterial side, permitting a direct angiography inside the vessel to measure the distal length of the drainage mouth at the right atrium, with a maximal diameter of 10 mm (Fig. 1 D). A 10 French Amplatzer sheath was then progressed from the venous side of the loop, advancing a 14× 10mm Vascular Plug II through the sheath, near the arteriovenous wire, that was maintained during the entire procedure (Fig. 2A, Video 2). After verifying the complete closure of the fistula, the device was released with embolization to the left pulmonary artery in the following beats (Video 3). The left femoral vein was then canalized to capture the device with a 20 × 10 Gooseneck, exteriorizing it through the femoral vein (Fig. 2B,
Video 4). A 12 × 10 mm-ductal occluder device was then implanted at the fistula drainage, verifying stability of the device before the release, and confirming a complete closure of the fistula with contralateral injections from the arterious side (Fig. 2C and D, Videos 5 and 6). The procedure was finalized without complications and the patient was discharged 24 h after the intervention under treatment with oral anticoagulant therapy. Six months after the procedure, she remains asymptomatic, with a control CT scan showing complete closure of the fistula with accurate position of the implanted device (Fig. 3). 3. Discussion 3.1. CAF origin CAF are rare, with an observed prevalence of less than 1% of patients undergoing coronary angiography [1]. CAF may be either congenital or acquired; sometimes related to disease processes that damage the vessels, such as infection, inflammation and malignancy. In addition, trauma to the vessels, whether iatrogenic (as in cardiothoracic surgery and interventional procedures) or non-iatrogenic, may lead to fistula formation [2,3]. In this patient, the association between previous pericardiectomy and CAF seems extremely rare, so that a casual association between both entities may be postulated. Cannulation of the right atrium for cardiopulmonary bypass during extracorporeal circulation has been reported as a cause of CAF [3] and may have been related to the development of this entity in this patient. Surgical manipulation
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
L. Unzué et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
3
Fig. 2. Percutaneous closure of the fistula. (A) Implant of a vascular plug 2 at the mouth of the fistula. (B) Embolization of the vascular Plug, captured with a Gooseneck. (C) Amplatzer duct occluder implantation at the distal segment of the fistula. (D) Final angiogram confirming complete occlusion of the flow.
of the visceral pericardium at the coronary sulcus may have also played a role starting with an inflammatory process of the coronary sinus drainage. 3.2. CAF, to treat or not to treat: events during follow-up There is controversy about the best management of CAF, given the fact that the natural history of this entity has not yet been well studied. Cases of spontaneous closure, although rare, have been reported, usually occurring in pediatric patients [2]. However, a considerable number of large fistulas have been documented to expand aneurysmally and even dissect or rupture, with fatal consequences [3]. In adult patients, the main consensus of opinions is in favor of operation once the condition is diagnosed. In contrast, little CAF found in children population could benefit from a provisional conservative management, with an intensive surveillance. Several reports have warned about the potential adverse events after CAF closure, with described cases of thrombosis or myocardial infarction during the follow-up [4]. The risk factors for these events have not been yet adequately identified. Recent works have suggested that large size, distal type of CAF [5], and CAF draining to the coronary sinus [6] may be at higher risk for coronary thrombosis; however, limited data are available, and the published articles collect only small series of cases, with a limited value. Reviewing the literature, there are only 11 published series with subsequent follow-up (Table 1), with a high variability of patients (children and adults) and closure techniques (surgical or transcatheter).
These series show significant differences between the rates of CAF thrombosis; probably related to the selected method employed for the surveillance of the patients, with very few cases with an available coronary angiogram during the follow-up. Although in these series the majority of CAF thrombosis occurred after surgical closure [4,5,12]; these cases corresponded to the more complex anatomy CAF (large fistulae with multiple drainages); so that definite conclusion cannot be inferred from these findings. Table 2 summarizes the reported cases of percutaneous closure of coronary artery fistulae in adult patients. The risk of recanalization is, however, relatively high in the majority of reports, with an estimated incidence of 15%–20%, independent of the closure technique. It usually follows an asymptomatic course, and seems to be associated to pediatric patients [4,7–9]. It seems therefore mandatory to routinely follow these patients after CAF closure, even if they remain asymptomatic. Compared with other modalities such as echocardiogram or computed tomography scan, the use of coronary angiogram during the follow-up allows for a direct visualization of the CAF, permitting the reintervention in the required cases; therefore we consider that it must be the preferred method for patients surveillance.
3.3. Percutaneous approach: wire-maintaining technique Percutaneous closure of CAF is always a challenging procedure, given the high variability of the CAF anatomy, requiring a specific approach for each case.
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
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L. Unzué et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Fig. 3. Control computed tomography showing the duct occluder (asterisk) at the mouth of the fistula.
For small fistulas with narrow drainage, percutaneous closure with coils has been reported, with selective canalization of the anomalous vessel using micro-catheters, and direct release of detachable coils [7,9,11]. However, in big fistulas, a detailed study of the anatomy is required, in order to choose the best strategy for the percutaneous closure. For these cases, an arteriovenous loop is suggested, to provide an accurate support for the device advance, allowing selective angiographies from the arterial side in order to guide the position and delivery of the device. Sometimes the selected device might not be optimal because of the complexity of the CAF. In these cases, maintaining the wire before the device release permits a rapid exchange to a new device, avoiding the reconstruction of a new arteriovenous loop. For this objective, a larger sheath is required, that allows the device passing while maintain the wire. In the reported case, preserving the wire was essential to enable the second device advance, facilitating the procedure, and reducing the time of the intervention. 3.4. Device selection The device must be deployed as distal as possible, to avoid occlusion of proximal coronary branches and to ensure a better stability at the narrowest point of the CAF. Over the years, various devices have been employed including detachable coils [10], Amplatzer vascular plug [16], Amplatzer duct occluders [13], and covered stents [17]. The type of device should be selected based on the fistula morphology. For narrow drainages, a double umbrella device could be selected in order to prevent migration, and for tubular drainages, a patent ductus arterious occluder may be suitable.
In this case, the vascular Plug II was firstly chosen considering that the three deformable disks would better adapt to the distal mouth of the CAF, avoiding the closure of the distal marginal obtuse branch. However, the low profile and the scarce radial force of the distal disk avoided the accurate apposition with the vessel walls, with immediate embolization of the device that was successfully captured in the pulmonary artery. A PDA occluder was then selected, with a higher profile of the distal disk that was compressed at the distal part of the mouth, providing a good stability of the device that was confirmed before the device release. In the reported series, the device embolization corresponds more frequently to detachable coils [7,9–11], sometimes recovered; but in the majority of cases abandoned at distal branches of pulmonary arteries. The use of Amplatzer devices seems to be a smarter solution for closure of large CAF, however, the size of the occluder must be carefully chosen, and the wire-maintaining technique is highly recommended for the use of these devices. A selective angiography of the CAF can help to determine the exact diameter of the narrowest point to choose the accurate size of the device. For Amplatzer devices, a 30%–50% oversize device is suggested.
4. Conclusion Transcatheter closure of CAF is a feasible and effective alternative therapy in patients with CAF with suitable anatomy. The use of an arteriovenous loop with the wire-maintaining technique may provide an accurate support for the device advance, allowing selective angiographies and permitting a rapid exchange to a new device if required. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.carrev.2017.03.002.
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
N
Patients
Age
Surgical/Transcatheter
Median follow-up
Outcomes after intervention
Outcomes in the follow-up
Reference
Okubo et al., 2001
13
Pediatric
6.3
Transcatheter
1.2
4 trivial shunt Followed by echo
[7]
Chegung et al., 2001
41
12 pediatric 29 adults
23.2
Surgical
9.1
4 Recurrences (all of them pediatric, surgical closure in 3, small shunts) Followed by echo or coronary angiogram (51%)
[8]
Armbsby et al., 2002
33
Pediatric adults
8
Transcatheter
2.8
27 follow-up: 5 small residual shunt Followed by echo
[9]
Gowda et al., 2010
16
11 pediatric 5 adults
1.6
12 transcatheter 4 surgical
2.3
9 (70%) complete occlusion 4 coils migration (without clinical sequelae) 4 patients postpericardiotomy syndrome requiring open pericardial drainage 1 re-explored for persistent bleeding at the arteriotomy 2 supraventricular tachycardia 2 ischemia 33 (85%) successful occlusion (5 with small residual shunt) 4 arrhythmias 1 coil migration Non-specified
[5]
Jama et al., 2011
29
Adults
49
Transcatheter
1.5
Oto et al., 2011
7
Adults
58.3
Transcatheter
4.5
Houet al., 2013
29
Pediatric
10
Surgical
10.1
Said et al. 2013
39
Pediatric
59
Surgical
6
3 perioperative myocardial infarction, one of them died 5 days after intervention
Wang et al. 2014
14
Pediatric
5.2
Transcatheter
3
None
Zhuet al., 2015
18
Adults
30.7
Transcatheter
3.25
Ponthier L, et al., 2015
23
13 pediatric 10 adults
6.9
13 transcatheter 4 surgical
9
11 complete closure 2 unsuccessful procedure 5 minimal residual shunt 100% success
3 AMI (the 3 in the surgical group, immediately, 9 months after and 42 years after closure). 2 residual leak Followed by echo 4 significant recanalization (transcatheter reintervention) Followed by echo or angiogram (62%) 1 minimal shunt Followed with computed tomography 1 AMI one month after 1 recanalization—TC closure—AMI 1 recanalization 1 right atrium thrombosis 1 mitral insufficiency Followed by different methods (echo/angiogram/computed tomography) 11 late mortality (10 non cardiac causes, 1 myocardial infarction) 1 non-fatal myocardial infarction 3 residual fistulas (6%), conservative management. 2 patients reoperated for severe tricuspid insufficiency None Followed by echo, computed tomography (2) 1 asymptomatic thrombosis of the fistula 4 minimal recanalization Followed by echo and computed tomography (10) 8 reinterventions (2 children) 1 postoperative AMI with LV dysfunction and final transplantation
89% complete closure. 11% trivial flow 2 device migrations (coils), 1 coronary thrombosis 1 coil embolization 1 atrial fibrillation (limited) 2 Residual shunt 1 hemoglobinuria 1 pneumothorax 1 wound infection
[10]
[11] [12]
[4]
L. Unzué et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
Table 1 Coronary artery fistulae series with surgical or transcatheter treatment, and events during follow-up.
[13] [14]
[15]
5
6
L. Unzué et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Table 2 Percutaneous closure of coronary artery fistulae in adults. N
Age
Sex
Symptoms
JAMA A
29 49
16 F Chest pain 15 Dyspnea 7 Palpitations 4 Fever 1
Harikrishnan S
3
3F
Collins
14 44
10 F 7 Chest pain 7 Palpitations 5 Dyspnea
Oto
7
3F
Zhang
Zhu
Regazzoli et al. Brown Nam Lee Su et al.
49 31 24
4 Chest pain 2 Dyspnea 1 Endocarditis 18 31 ± 11 11 F Dyspnea in 9 Chest pain in 3 Heart failure in 1 8 18–56 4F Dyspnea in 5 Chest pain in 3
1 1 1
58
Not reported
63 56 62
F F F
Chest pain Chest pain Chest pain
Fistula
Device
Follow-up duration
Events
Ref
15 from LAD to PA (11) RV (2) or CS (2) 13 from RCA to PA (5) RV (1) RA (1) CS (1) or SVC (3) 7 from Cx to PA (2), RA (2), CS (2), SVC (1) 1 from aortic arch to PA LCX to LV RCA to RA RCA to RA
Coils in 31 Amplatzer vascular Plug in 2 Amplatzer vascular Occluder in 1 Covered stent in 1 Embolization particles in 1
1.5 years
22% trivial recanalization 22% large recanalization
[10]
Dissection and spontaneous closure Nitinol ductal occluder Nitinol ductal occluder Coils
40 ± 23 months
1 acute myocardial infarction
[18]
2.6 ± 2.1 years
3 unsuccessful closure 2 device embolizations 1 vessel dissection
[19]
Coils
From 3 to 7 years
[11]
Amplatzer Vascular Plug II, patent ductus arteriosus occlude, muscular ventricular septal defect occluder Amplatzer duct occluder, Amplatzer ventricular septal occluder, Amplatzer vascular plug, coils Amplatzer vascular Plug IV Amplatzer vascular Plug Amplatzer vascular Plug IV
1–54 months
2 asymptomatic embolizations 1 minimal recanalization 2 unsuccessful closure 1 recanalization 1 fistula thrombosis
4.7 ± 3.2 years
1 residual shunt
[14]
6 months None 1 year
None None None
[21] [22] [23]
6 from LCA, 7 from RCA, 1 from both. Drainage: 5 in PA, 4 in RV, 3 in RA LAD to PA (3) RCA to PA (2) Cx to PA (2) RCA (11), Cx (5), LAD (1) Drainage: RV (10), RA (4), CS (2), LV (2) From RCA (7) and LAD (1) to RV (4), RA (2), PA (1) and LV (1) From LAD to PA From LCA and RCA to PA From LAD and RCA to pulmonary artery
[20]
LAD: left anterior descending artery. PA: pulmonary artery. RV: right ventricle. CS: coronary sinus. RCA: right coronary artery. RA: right atrium. SVC: superior vena cava. Cx: circumflex coronary artery. LCA: left coronary artery. RCA: right coronary artery.
References [1] Latson LA. Core curriculum coronary artery fistulas: how to manage them. 2007; 116:110–6. [2] Yilmazer MM, Demir F, Yolbaş I, Bilici M. Spontaneous closure of a symptomatic coronary artery fistula just within a few days of newborn period. Congenit Heart Dis 2014;9(1):E27–30 [d]. [3] Rajs J, Brodin LA, Hertzfeld I, Larsen FF. Death related to coronary artery fistula after rupture of an aneurysm to the coronary sinus. Am J Forensic Med Pathol 2001;22(1):58–61. [4] Said SM, Burkhart HM, Schaff HV, Connolly HM, Phillips SD, Suri RM, et al. Late outcome of repair of congenital coronary artery fistulas—a word of caution. J Thorac Cardiovasc Surg 2013;145(2):455–60. [5] Gowda ST, Latson LA, Kutty S, Prieto LR. Intermediate to long-term outcome following congenital coronary artery fistulae closure with focus on thrombus formation; 2010. [6] Valente AM, Lock JE, Gauvreau K, Rodriguez-Huertas E, Joyce C, Armsby L, et al. Predictors of long-term adverse outcomes in patients with congenital coronary artery fistulae. Circ Cardiovasc Interv 2010;3(2):134–9. [7] Okubo M, Nykanen D, Benson LN. Outcomes of transcatheter embolization in the treatment of coronary artery fistulas. Catheter Cardiovasc Interv 2001;517:510–7. [8] Cheung DLC, Au W, Cheung HHC, Chiu CSW, Lee W. Coronary artery fistulas: longterm results of surgical correction; 2001 4975. [9] Armsby LR, Keane JF, Sherwood MC, Forbess JM, Perry SB, Lock JE. Management of coronary artery fistulae patient selection and results of transcatheter closure. J Am Coll Cardiol 2002;39:1026–32. [10] Jama A, Barsoum M, Bjarnason H, Holmes Jr DR, Rihal CS. Percutaneous closure of congenital coronary artery fistulae: results and angiographic follow-up. JACC Cardiovasc Interv 2011;4(7):814–21. [11] Oto I, Aytemir K, Barbaros C. Percutaneous closure of coronary artery fistulae in adults with intermediate term follow-up results. 2011;24:216–22. [12] Hou B, Ma W, Zhang J, Du M, Sun H. Surgical management of left circum fl ex coronary artery fistula: a 25-year single-center experience; 2014.
[13] Wang C, Zhou K, Li Y, Qiao L, Wang Y. Congenital heart disease percutaneous transcatheter closure of congenital coronary artery fistulae with patent ductus arteriosus occluder in children: focus on patient selection and intermediate-term follow-up results. J Invasive Cardiol 2014;26:339–46. [14] Zhu X, Zhang D, Han X, Cui C. Transcatheter closure of congenital coronary artery fistulae: immediate and long-term follow-up results. Clin Cardiol 2009;512:506–12. [15] Ponthier L, Brenot P, Lambert V, Baruteau JRA. Closure of isolated congenital coronary artery fistula: long-term outcomes and rate of re-intervention; 2015 1728–34. [16] Fischer G, Apostolopoulou SC, Rammos S, Kiaffas M, Kramer HH. Transcatheter closure of coronary arterial fistulas using the new Amplatzer vascular plug. Cardiol Young 2007;17:283–7. [17] Mullasari AS, Umesan CV, Kumar KJ. Transcatheter closure of coronary artery to pulmonary artery fistula using covered stents. Heart 2002;87:60. [18] Harikrishnan S, Bimal F, Ajithkumar V, Bhat A, Krishnamoorthy KM, Sivasubramonian S, et al. Percutaneous treatment of congenital coronary arteriovenous fistulas. J Interv Cardiol 2011;24(3):208–15. [19] Collins N, Mehta R, Benson L, Horlick E. Percutaneous coronary artery fistula closure in adults: technical and procedural aspects. Catheter Cardiovasc Interv 2007;69(6): 872–80. [20] Zhang ZG, Xu XD, Bai Y, Zhang XL, Tan HW, Zhu YF, et al. Transcatheter closure of medium and large congenital coronary artery fistula using wire-maintaining technique. J Cardiol 2015;66(6):509–13. [21] Regazzoli D, Giglio M, Besana F, Leone PP, Tanaka A, Ancona MB, et al. Multimodality evaluation of percutaneous closure of coronary fistula using AMPLATZER Vascular Plug IV. Int J Cardiol 2016;225:381–3. [22] Brown MA, Balzer D, Lasala J. Multiple coronary artery fistulae treated with a single Amplatzer vascular plug: check the back door when the front is locked. Catheter Cardiovasc Interv 2009;73(3):390–4. [23] Lee SN, Lee J, Ji EY, Jang BH, Lee HH, Moon KW. Percutaneous management of coronary artery-to-pulmonary artery fistula using an Amplatzer vascular plug with the trans-radial approach. Intern Med 2016;55(8):929–33.
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature☆ Leire Unzué a,⁎, Eulogio García a, Belén Díaz-Antón b, Javier Fernández-Portales c, Rodrigo Teijeiro a, Miguel Rodríguez-del-Río d a
Interventional Cardiology, Hospital Universitario Madrid Montepríncipe, Madrid, Spain Cardiac Image Unit, Hospital Universitario Madrid Montepríncipe, Madrid, Spain Interventional Cardiology, Hospital San Pedro de Alcántara, Cáceres, Spain d Anesthesiology, Hospital Universitario Madrid Montepríncipe, Madrid, Spain b c
a r t i c l e
i n f o
Article history: Received 10 February 2017 Received in revised form 28 February 2017 Accepted 1 March 2017 Available online xxxx Keywords: Coronary artery fistulae Percutaneous closure Ductal occluder
a b s t r a c t Coronary artery fistulae (CAF) are uncommon heart defects defined as a communication between a coronary artery and a cardiac chamber or vascular structure. They are frequently asymptomatic; nevertheless, they can produce angina, dyspnea or cardiac failure. CAF are believed to be congenital; however, isolated cases of CAF have been described as rare complications of cardiac surgery. We report the percutaneous closure of a giant CAF in an adult patient with angina and previous pericardiectomy. © 2017 Elsevier Inc. All rights reserved.
Contents 1. 2. 3.
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Introduction . . . . . . . . . . . . . . . . . . . . . . Case report. . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . 3.1. CAF origin . . . . . . . . . . . . . . . . . . . . 3.2. CAF, to treat or not to treat: events during follow-up 3.3. Percutaneous approach: wire-maintaining technique 3.4. Device selection . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction Coronary artery fistulae (CAF) are uncommon heart defects defined as a communication between a coronary artery and a cardiac chamber or vascular structure [1]. They are frequently asymptomatic; nevertheless, they can produce angina, dyspnea or cardiac failure.
☆ Conflict of interest statement: The authors have no conflicts of interest to declare. ⁎ Corresponding author at: Hospital Universitario Madrid Montepríncipe, Interventional Cardiology Unit, Avda Montepríncipe 25, 28668, Boadilla del Monte, Madrid, Spain. Tel.: +34 917089900. E-mail address: [email protected] (L. Unzué).
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CAF are believed to be congenital; however, isolated cases of CAF have been described as rare complications of cardiac surgery [2,3]. We report the percutaneous closure of a giant CAF in an adult patient with angina and previous pericardiectomy. 2. Case report A 69-year-old woman with a three-month history of angina and minimal effort dyspnea was admitted for percutaneous closure of a left coronary circumflex (LCX) CAF. The patient had suffered a constrictive pericarditis 14 years before, with a normal coronary angiogram followed by a surgical pericardiectomy; and was under oral anticoagulant therapy with apixaban due to chronic atrial fibrillation. A right
http://dx.doi.org/10.1016/j.carrev.2017.03.002 1553-8389/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
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L. Unzué et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Fig. 1. (A) Coronary angiogram from the Aorta (Ao) showing the fistula with drainage in the right atrium (RA). (B) Advance of a hydrophilic wire through the fistulous vessel to the right atrium. (C) Arteriovenous loop reaching the inferior cava vein (ICV). (D) Selective angiography of the fistula from the aortic side.
catheterization ruled out significant constriction showing data concordant with high cardiac output (11l/min). The coronary angiogram performed in another center showed a big circumflex coronary artery, with a tortuous pathway and an independent drainage into the right atrium, through the coronary sinus (Fig. 1A). Given the high risk of a new surgical intervention (Euroscore II 4.7%), the patient's case was discussed in the Heart Team and a percutaneous closure of the coronary artery fistula was planned. Right femoral artery was canalized, advancing a multipurpose 6 French catheter to the left aortic coronary sinus, pushing a 0.35″hydrophilic Terumo wire through the tortuous pathway of the fistula, reaching the right atrium (Fig. 1B, Video 1). Given the need of an accurate support to advance the closure device, an arteriovenous loop was performed, canalizing the right femoral vein, to capture the wire in the right atrium with a 30 mm gooseneck, externalizing it through the venous access to establish the circuit (Fig. 1C). This maneuver allowed for the selective canalization of the fistula from the arterial side, permitting a direct angiography inside the vessel to measure the distal length of the drainage mouth at the right atrium, with a maximal diameter of 10 mm (Fig. 1 D). A 10 French Amplatzer sheath was then progressed from the venous side of the loop, advancing a 14× 10mm Vascular Plug II through the sheath, near the arteriovenous wire, that was maintained during the entire procedure (Fig. 2A, Video 2). After verifying the complete closure of the fistula, the device was released with embolization to the left pulmonary artery in the following beats (Video 3). The left femoral vein was then canalized to capture the device with a 20 × 10 Gooseneck, exteriorizing it through the femoral vein (Fig. 2B,
Video 4). A 12 × 10 mm-ductal occluder device was then implanted at the fistula drainage, verifying stability of the device before the release, and confirming a complete closure of the fistula with contralateral injections from the arterious side (Fig. 2C and D, Videos 5 and 6). The procedure was finalized without complications and the patient was discharged 24 h after the intervention under treatment with oral anticoagulant therapy. Six months after the procedure, she remains asymptomatic, with a control CT scan showing complete closure of the fistula with accurate position of the implanted device (Fig. 3). 3. Discussion 3.1. CAF origin CAF are rare, with an observed prevalence of less than 1% of patients undergoing coronary angiography [1]. CAF may be either congenital or acquired; sometimes related to disease processes that damage the vessels, such as infection, inflammation and malignancy. In addition, trauma to the vessels, whether iatrogenic (as in cardiothoracic surgery and interventional procedures) or non-iatrogenic, may lead to fistula formation [2,3]. In this patient, the association between previous pericardiectomy and CAF seems extremely rare, so that a casual association between both entities may be postulated. Cannulation of the right atrium for cardiopulmonary bypass during extracorporeal circulation has been reported as a cause of CAF [3] and may have been related to the development of this entity in this patient. Surgical manipulation
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
L. Unzué et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
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Fig. 2. Percutaneous closure of the fistula. (A) Implant of a vascular plug 2 at the mouth of the fistula. (B) Embolization of the vascular Plug, captured with a Gooseneck. (C) Amplatzer duct occluder implantation at the distal segment of the fistula. (D) Final angiogram confirming complete occlusion of the flow.
of the visceral pericardium at the coronary sulcus may have also played a role starting with an inflammatory process of the coronary sinus drainage. 3.2. CAF, to treat or not to treat: events during follow-up There is controversy about the best management of CAF, given the fact that the natural history of this entity has not yet been well studied. Cases of spontaneous closure, although rare, have been reported, usually occurring in pediatric patients [2]. However, a considerable number of large fistulas have been documented to expand aneurysmally and even dissect or rupture, with fatal consequences [3]. In adult patients, the main consensus of opinions is in favor of operation once the condition is diagnosed. In contrast, little CAF found in children population could benefit from a provisional conservative management, with an intensive surveillance. Several reports have warned about the potential adverse events after CAF closure, with described cases of thrombosis or myocardial infarction during the follow-up [4]. The risk factors for these events have not been yet adequately identified. Recent works have suggested that large size, distal type of CAF [5], and CAF draining to the coronary sinus [6] may be at higher risk for coronary thrombosis; however, limited data are available, and the published articles collect only small series of cases, with a limited value. Reviewing the literature, there are only 11 published series with subsequent follow-up (Table 1), with a high variability of patients (children and adults) and closure techniques (surgical or transcatheter).
These series show significant differences between the rates of CAF thrombosis; probably related to the selected method employed for the surveillance of the patients, with very few cases with an available coronary angiogram during the follow-up. Although in these series the majority of CAF thrombosis occurred after surgical closure [4,5,12]; these cases corresponded to the more complex anatomy CAF (large fistulae with multiple drainages); so that definite conclusion cannot be inferred from these findings. Table 2 summarizes the reported cases of percutaneous closure of coronary artery fistulae in adult patients. The risk of recanalization is, however, relatively high in the majority of reports, with an estimated incidence of 15%–20%, independent of the closure technique. It usually follows an asymptomatic course, and seems to be associated to pediatric patients [4,7–9]. It seems therefore mandatory to routinely follow these patients after CAF closure, even if they remain asymptomatic. Compared with other modalities such as echocardiogram or computed tomography scan, the use of coronary angiogram during the follow-up allows for a direct visualization of the CAF, permitting the reintervention in the required cases; therefore we consider that it must be the preferred method for patients surveillance.
3.3. Percutaneous approach: wire-maintaining technique Percutaneous closure of CAF is always a challenging procedure, given the high variability of the CAF anatomy, requiring a specific approach for each case.
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
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L. Unzué et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Fig. 3. Control computed tomography showing the duct occluder (asterisk) at the mouth of the fistula.
For small fistulas with narrow drainage, percutaneous closure with coils has been reported, with selective canalization of the anomalous vessel using micro-catheters, and direct release of detachable coils [7,9,11]. However, in big fistulas, a detailed study of the anatomy is required, in order to choose the best strategy for the percutaneous closure. For these cases, an arteriovenous loop is suggested, to provide an accurate support for the device advance, allowing selective angiographies from the arterial side in order to guide the position and delivery of the device. Sometimes the selected device might not be optimal because of the complexity of the CAF. In these cases, maintaining the wire before the device release permits a rapid exchange to a new device, avoiding the reconstruction of a new arteriovenous loop. For this objective, a larger sheath is required, that allows the device passing while maintain the wire. In the reported case, preserving the wire was essential to enable the second device advance, facilitating the procedure, and reducing the time of the intervention. 3.4. Device selection The device must be deployed as distal as possible, to avoid occlusion of proximal coronary branches and to ensure a better stability at the narrowest point of the CAF. Over the years, various devices have been employed including detachable coils [10], Amplatzer vascular plug [16], Amplatzer duct occluders [13], and covered stents [17]. The type of device should be selected based on the fistula morphology. For narrow drainages, a double umbrella device could be selected in order to prevent migration, and for tubular drainages, a patent ductus arterious occluder may be suitable.
In this case, the vascular Plug II was firstly chosen considering that the three deformable disks would better adapt to the distal mouth of the CAF, avoiding the closure of the distal marginal obtuse branch. However, the low profile and the scarce radial force of the distal disk avoided the accurate apposition with the vessel walls, with immediate embolization of the device that was successfully captured in the pulmonary artery. A PDA occluder was then selected, with a higher profile of the distal disk that was compressed at the distal part of the mouth, providing a good stability of the device that was confirmed before the device release. In the reported series, the device embolization corresponds more frequently to detachable coils [7,9–11], sometimes recovered; but in the majority of cases abandoned at distal branches of pulmonary arteries. The use of Amplatzer devices seems to be a smarter solution for closure of large CAF, however, the size of the occluder must be carefully chosen, and the wire-maintaining technique is highly recommended for the use of these devices. A selective angiography of the CAF can help to determine the exact diameter of the narrowest point to choose the accurate size of the device. For Amplatzer devices, a 30%–50% oversize device is suggested.
4. Conclusion Transcatheter closure of CAF is a feasible and effective alternative therapy in patients with CAF with suitable anatomy. The use of an arteriovenous loop with the wire-maintaining technique may provide an accurate support for the device advance, allowing selective angiographies and permitting a rapid exchange to a new device if required. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.carrev.2017.03.002.
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
N
Patients
Age
Surgical/Transcatheter
Median follow-up
Outcomes after intervention
Outcomes in the follow-up
Reference
Okubo et al., 2001
13
Pediatric
6.3
Transcatheter
1.2
4 trivial shunt Followed by echo
[7]
Chegung et al., 2001
41
12 pediatric 29 adults
23.2
Surgical
9.1
4 Recurrences (all of them pediatric, surgical closure in 3, small shunts) Followed by echo or coronary angiogram (51%)
[8]
Armbsby et al., 2002
33
Pediatric adults
8
Transcatheter
2.8
27 follow-up: 5 small residual shunt Followed by echo
[9]
Gowda et al., 2010
16
11 pediatric 5 adults
1.6
12 transcatheter 4 surgical
2.3
9 (70%) complete occlusion 4 coils migration (without clinical sequelae) 4 patients postpericardiotomy syndrome requiring open pericardial drainage 1 re-explored for persistent bleeding at the arteriotomy 2 supraventricular tachycardia 2 ischemia 33 (85%) successful occlusion (5 with small residual shunt) 4 arrhythmias 1 coil migration Non-specified
[5]
Jama et al., 2011
29
Adults
49
Transcatheter
1.5
Oto et al., 2011
7
Adults
58.3
Transcatheter
4.5
Houet al., 2013
29
Pediatric
10
Surgical
10.1
Said et al. 2013
39
Pediatric
59
Surgical
6
3 perioperative myocardial infarction, one of them died 5 days after intervention
Wang et al. 2014
14
Pediatric
5.2
Transcatheter
3
None
Zhuet al., 2015
18
Adults
30.7
Transcatheter
3.25
Ponthier L, et al., 2015
23
13 pediatric 10 adults
6.9
13 transcatheter 4 surgical
9
11 complete closure 2 unsuccessful procedure 5 minimal residual shunt 100% success
3 AMI (the 3 in the surgical group, immediately, 9 months after and 42 years after closure). 2 residual leak Followed by echo 4 significant recanalization (transcatheter reintervention) Followed by echo or angiogram (62%) 1 minimal shunt Followed with computed tomography 1 AMI one month after 1 recanalization—TC closure—AMI 1 recanalization 1 right atrium thrombosis 1 mitral insufficiency Followed by different methods (echo/angiogram/computed tomography) 11 late mortality (10 non cardiac causes, 1 myocardial infarction) 1 non-fatal myocardial infarction 3 residual fistulas (6%), conservative management. 2 patients reoperated for severe tricuspid insufficiency None Followed by echo, computed tomography (2) 1 asymptomatic thrombosis of the fistula 4 minimal recanalization Followed by echo and computed tomography (10) 8 reinterventions (2 children) 1 postoperative AMI with LV dysfunction and final transplantation
89% complete closure. 11% trivial flow 2 device migrations (coils), 1 coronary thrombosis 1 coil embolization 1 atrial fibrillation (limited) 2 Residual shunt 1 hemoglobinuria 1 pneumothorax 1 wound infection
[10]
[11] [12]
[4]
L. Unzué et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002
Table 1 Coronary artery fistulae series with surgical or transcatheter treatment, and events during follow-up.
[13] [14]
[15]
5
6
L. Unzué et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Table 2 Percutaneous closure of coronary artery fistulae in adults. N
Age
Sex
Symptoms
JAMA A
29 49
16 F Chest pain 15 Dyspnea 7 Palpitations 4 Fever 1
Harikrishnan S
3
3F
Collins
14 44
10 F 7 Chest pain 7 Palpitations 5 Dyspnea
Oto
7
3F
Zhang
Zhu
Regazzoli et al. Brown Nam Lee Su et al.
49 31 24
4 Chest pain 2 Dyspnea 1 Endocarditis 18 31 ± 11 11 F Dyspnea in 9 Chest pain in 3 Heart failure in 1 8 18–56 4F Dyspnea in 5 Chest pain in 3
1 1 1
58
Not reported
63 56 62
F F F
Chest pain Chest pain Chest pain
Fistula
Device
Follow-up duration
Events
Ref
15 from LAD to PA (11) RV (2) or CS (2) 13 from RCA to PA (5) RV (1) RA (1) CS (1) or SVC (3) 7 from Cx to PA (2), RA (2), CS (2), SVC (1) 1 from aortic arch to PA LCX to LV RCA to RA RCA to RA
Coils in 31 Amplatzer vascular Plug in 2 Amplatzer vascular Occluder in 1 Covered stent in 1 Embolization particles in 1
1.5 years
22% trivial recanalization 22% large recanalization
[10]
Dissection and spontaneous closure Nitinol ductal occluder Nitinol ductal occluder Coils
40 ± 23 months
1 acute myocardial infarction
[18]
2.6 ± 2.1 years
3 unsuccessful closure 2 device embolizations 1 vessel dissection
[19]
Coils
From 3 to 7 years
[11]
Amplatzer Vascular Plug II, patent ductus arteriosus occlude, muscular ventricular septal defect occluder Amplatzer duct occluder, Amplatzer ventricular septal occluder, Amplatzer vascular plug, coils Amplatzer vascular Plug IV Amplatzer vascular Plug Amplatzer vascular Plug IV
1–54 months
2 asymptomatic embolizations 1 minimal recanalization 2 unsuccessful closure 1 recanalization 1 fistula thrombosis
4.7 ± 3.2 years
1 residual shunt
[14]
6 months None 1 year
None None None
[21] [22] [23]
6 from LCA, 7 from RCA, 1 from both. Drainage: 5 in PA, 4 in RV, 3 in RA LAD to PA (3) RCA to PA (2) Cx to PA (2) RCA (11), Cx (5), LAD (1) Drainage: RV (10), RA (4), CS (2), LV (2) From RCA (7) and LAD (1) to RV (4), RA (2), PA (1) and LV (1) From LAD to PA From LCA and RCA to PA From LAD and RCA to pulmonary artery
[20]
LAD: left anterior descending artery. PA: pulmonary artery. RV: right ventricle. CS: coronary sinus. RCA: right coronary artery. RA: right atrium. SVC: superior vena cava. Cx: circumflex coronary artery. LCA: left coronary artery. RCA: right coronary artery.
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Please cite this article as: Unzué L, et al, Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.03.002