Catheterization and Cardiovascular Diagnosis 18:240-243 (1 989)

Treatment of Coronary Artery Stenosis and Coronary Arteriovenous Fistula

by I n terven t iona I Card io logy Techniques

Khiem Nguyen, MD, Richard K. Myler, MD, Grant Hieshima, MD, Mohammed Ashraf, MD, and Simon H. Stertzer, MD

Complications associated with coronary arteriovenous fistulae (CAVF) include conges- tive heart failure, bacterial endocarditis, fistula rupture, and angina secondary to the “coronary steal” phenomenon. Traditional treatment of large CAVF is surgical ligation. In this report, we describe a modified microcoil embolization and guidewire technique for percutaneous closure of CAVF.

Key words: percutaneous closure, “coronary steal,” microcoil embolization, guidewire

INTRODUCTION

Congenital coronary artery fistulae constitute the most common hemodynamically significant coronary anomaly [ 11. Fistulae from the right coronary artery are slightly more common than those from the left coronary artery, and bilateral fistulae are present in 4-5% of cases [ 2 , 3 ] . Over 90% of the fistulae drain into the venous circulation (right ventricle, 41%; right atrium, 26%; pulmonary ar- tery, 17%; coronary sinus, 7%, and superior vena cava, l%), while the remaining fistulae drain into the arterial circulation (left atrium, 5%; left ventricle, 3%) [ l ] . When a fistula drains into the venous circulation, a sig- nificant left-to-right shunt may be present [ 3 ] . Runoff through a fistula may lower intracoronary diastolic pres- sure and produce myocardial ischemia in some patients by a “coronary steal” phenomenon [l]. Recommended treatment of large coronary fistulae is surgical ligation [3-51. In this report, we describe successful percutane- ous transluminal closure of a coronary arteriovenous fis- tula (CAVF) as well as balloon angioplasty of an adja- cent stenosis.

CASEREPORT

This 54-year-old white female had angina pectoris 7 years prior to admission. Cardiac catheterization was performed 5 years prior to admission and showed a min- imal narrowing (25% diameter stenosis) in the mid left anterior descending artery (LAD), and a fistula from the proximal LAD to the pulmonary artery (PA). At the time it was elected to treat her angina medically, with good results. However, 1 month prior to the current illness, she was admitted to the hospital because of progressively

increasing angina (Canadian Cardiovascular Society Class 111). An EKG during chest pain revealed ST and T wave abnormalities in the anterior leads.

Physical examination showed a blood pressure of 120/ 80 and a pulse of 70. The lungs were clear. The jugular venous pressure and carotid arterial pulses were normal. The cardiac point of maximal impulse was in the mid- clavicular line; there were no heaves or thrills. The sec- ond heart sound was of normal intensity and had a nor- mal split with respiration; neither an S3 or S4 gallop or murmur was detected. The EKG showed sinus rhythm and nonspecific T wave flattening in the anterior leads. The chest roentgenogram showed a normal cardiac sil- houette and a normal pulmonary vascular pattern.

During cardiac catheterization, the right and left ven- tricular filling pressures were normal. An oximetric run failed to show a significant step-up in oxygen saturation from the SVC to the PA. Coronary arteriography showed progression of the LAD stenosis to an 80% diameter reduction, as well as a LAD-PA fistula arising 1 cm proximal to the stenosis. The patient was referred for treatment.

Coronary angioplasty was performed with a Judkins left guiding catheter, a 3.5 mm Profile Plus dilatation

From the San Francisco Heart Institute, Seton Medical Center, Daly City, and the Department of Neuroradiology, University of California, San Francisco, California.

Received March 14, 1989; accepted June 24, 1989.

Address reprint requests to Richard K. Myler, M.D., San Francisco Heart Institute, 1900 Sullivan Avenue, Daly City, CA 94015.

0 1989 Alan R. Liss , Inc.

Coronary Stenosis and Fistula 241

Fig. 1. RAO-30” projection of left anterior descending coronary artery showing stenosis (solid arrow) and fistula (open arrow) (A) before and (B) after angioplasty. C: Tracker Tracer Cannula

in fistula (arrow) for insertion of (D) rninibrushes. E: Following procedures with widely patent LAD and occluded fistula. Note rninibrushes (open arrow).

balloon catheter (USCI)’ over a 0.014” flexible steer- FISTULA CLOSURE TECHNIQUE able guidewire. The pre-angioplasty pressure gradient across the stenosis was 50 mm Hg. Following angio- plasty, the residual “stenosis” was less than lo%, and the pressure gradient was 5 mm Hg (Fig. 1, 2).

To close the CAVF, the left coronary artery was en- gaged with an 8 F J L A guide catheter. A 0.014” very flexible guidewire was used to cannulate the fistula. A Tracker (Target Therapeutics)2 catheter was advanced over the guidewire intoihe fistula, and the guidewire was

’Target Therapeutics, San Jose, CA. ‘United States Catheter and Instrument Co., Inc. Division of C.R. Bard, Billerica, MA.

242 Nguyen et al.

Fig. 2. Left lateral projection of LAD showing stenosis (solid arrow) and fistula (open arrow) (A) before and (B) after angioplasty and (C) after fistula occlusion by minibrushes (arrow).

removed. A Hilal embolization microcoil (C00k)~ was loaded into the catheter, then embolized into the fistula with 3 ml of saline solution. The coronary guidewire was reintroduced into the Tracker catheter and advanced to compact the microcoil in the fistula. This procedure was repeated with a total of 6 Cook embolization microcoils, until injection of contrast through the guide catheter showed no flow in the fistula (Fig. 1, 2).

The procedures of angioplasty and fistula occlusion were well tolerated by the patient. She was discharged on diltiazem 30 mg qid, aspirin 325 mg qd, and dipyridam- ole 75 mg bid.

DISCUSSION

Hemodynamic disturbances created by CAVF consist of a left-to-right shunt of variable magnitude and myo- cardial ischemia secondary to “coronary steal” [ 1,3]. Most patients with this anomaly not treated surgically survive to adulthood. The majority are asymptomatic un- til the fifth or sixth decade, when signs and symptoms of left ventricular failure occur secondary to the left-to-right shunt [3,6]. It is universally agreed that surgical closure of the fistula is indicated in patients with significant left- to-right shunts (pulmonary-to-systemic blood flow ratios exceeding 1.5 to 1.0) [3,7]. However, for the asymp- tomatic patients without a significant left-to-right shunt, the decision regarding surgical correction is more com- plex. Ischemia has been documented in some patients with CAVF and no atherosclerosis secondary to “cor- onary steal” [I]. In addition to angina and congestive heart failure, bacterial endocarditis [5 J , fistula rupture [S], and progressive aneurysmal dilatation of CAVF [9] have been reported. Since spontaneous fistula closure is rare and the risk of surgical closure of the fistula is sig-

3Cook, Inc., Bloomington, IN.

nificantly lower in young patients [3], some authors have suggested elective fistula ligation in young patients, in- cluding those who are asymptomatic [3].

The present patient has a 7-year history of angina prior to angioplasty and fistula closure. It is of interest that a cardiac catheterization performed 5 years ago showed only minimal LAD narrowing distal to the origin of the LAD-PA fistula. The patient probably had “coronary steal” at that time. Since the patient belonged to a some- what older age group, and perioperative complications are more frequent for surgical ligation of CAVF in pa- tients older than 20 years [3], it seemed appropriate to recommend medical therapy at that time.

Five years later, her angina had accelerated; repeat coronary arteriography showed significant progression of the LAD stenosis. Hemodynamic and oximetric mea- surements at this time failed to show right-sided diastolic pressure overload or a significant pulmonic-to-systemic flow ratio (Qp/Qs). Despite this, it seemed reasonable to proceed with fistula closure at the time of the angioplasty of the LAD. A successful fistula closure might decrease her future risks, albeit small, of bacterial endocarditis or progressive CAVF enlargement.

Transcatheter embolization with coils, gelfoam, or glue has been reported for percutaneous closure of in- tracranial and systemic arteriovenous fistulae [ 10,111. This technique was successfully adapted, in the present case, for the coronary circulation. To the best of our knowledge, percutaneous closure of a CAVF by this pro- cedure has not been previously reported. Although a va- riety of materials is available for embolization, we chose Cook Hilal embolization microcoils. These are in the form of “mini-brushes’’ to ensure compaction within the lumen of the fistula and to avoid embolization into the pulmonary artery. Percutaneous closure was performed with great ease in this particular patient, but it should be noted that her fistula was smaII. This transcatheter tech-

Coronary Stenosis and Fistula 243

4. Cooley DA, Ellis PR: Surgical considerations of coronary arterial fistula. Am J Cardiol 10:467-474, 1962.

5 . Rittenhouse EA, Doty DB, Ehrenhaft JL: Congenital coronary artery-cardiac chamber fistula. Ann Thorac Surg 20:468-485, 1975.

6. Perloff JK: Congenital coronary artery fistula. In: “The Clinical Recognition of Congenital Heart Disease.” 3rd ed. Philadelphia. W.B. Saunders Co. 1987, pp 511-525.

7. Hobbs RE, Milit HD, Raghavan RV, Mooldle DS, Sheldon WC: Coronary artery fistulae: A 10 year review. Clev Clin Q 49: 191-197, 1982.

8. Habermann JH, Howard ML, Johnson ES: Rupture of the coro- nary sinus with hemopericardium: A rare complication of coro- nary arteriovenous fistula. Circulation 28:1143-1144, 1963.

9. Querimit AS, Rowe GG: Localization of coronary arteriovenous fistula by indicator-dilution curves. Am J Cardiol 27:114-119, 1971.

10. Yang P, Halbach V, Higashida RT, Hieshima GB: Platinum wires: A new transvascular embolic agent. Am J Neuroradiol

11. Halbach V, Higashida RT, Hieshima GB, Harden CW, Yang P: Transvenous embolization of direct carotid cavernous fistula. Am J Neuroradiol 9(7):741 e749, 1988.

9:447-550, 1988.

nique may not be applicable to all coronary fistulae, especially when they are very large. Although our expe- rience with this technique is preliminary, percutaneous closure of CAVF can be performed safely, effectively, and may be an excellent alternative to surgical ligation in selected cases.

REFERENCES

Levin DC, Fellows KE, Abrams HL: Hemodynamically signifi- cant primary anomalies of the coronary arteries. Angiographic aspects. Circulation 58:25-34, 1978. Baim DS, Kline H, Silverman JF: Bilateral coronary-pulmonary artery fistulae: Report of five cases and review of the literature. Circulation 65:810-8 15, 1982. Liberthson RR, Sagar K, Berkoben JP, Weintraub RM, Levine FH: Congenital coronary arteriovenous fistula. Report of 13 pa- tients. Review of the literature and delineation of the manage- ment, Circulation 59:849-854, 1979.