Transcatheter Closure of a Coronary Fistula with an Amplatzer? Vascular Plug: Should a Retrograde Approach Be Standard?

Coronary artery fistulae are rare disorders. Only 2 reports in the medical literature discuss the use of vascular plugs to occlude coronary fistulae, and the same device-the Amplatzer Vascular Plug-was deployed via different techniques to treat those patients. The safety, the feasibility, and the standard approach to deployment have yet to be established. Herein, we describe the case of a 15-year-old boy who presented with a continuous murmur at the left sternal border. The patient was diagnosed with a large coronary fistula that originated from the right coronary artery and emptied into the right atrium. He underwent transcatheter closure of the fistula. We placed a 14-mm Amplatzer Vascular Plug into the narrowest part of the fistula, which resulted in complete occlusion and an excellent outcome. Our retrograde approach is simple and obviates the need to establish arteriovenous loops or to insert additional devices, such as coils. In this report, we compare our results with those of the 2 previous reports. To our knowledge, this is only the 2nd report that describes the closure of a coronary fistula in an adolescent patient by use of an Amplatzer Vascular Plug.     

经导管介入治疗冠状动脉瘘

目的：探讨经导管介入治疗冠状动脉瘘的方法及临床疗效。方法：经导管堵塞冠状动脉瘘14例，平均年龄7．1岁。结果：13例应用弹簧圈堵塞，平均瘘口大小为3．65mm，除3例失败外均获成功；1例（瘘口6．6mm）应用Amplatzer动脉导管未闭堵塞器堵塞成功。所有病例随访1个月－4年，均无残余分流及任何并发症。结论：经导管介入治疗冠状动脉瘘具有良好的临床疗效及安全性。可控弹簧圈一般用于堵塞瘘口较小的冠状动脉瘘，而瘘口较大的冠状动脉瘘可选用Amplatzer动脉导管未闭堵塞器。     

An elephant trunk appearance—what is the diagnosis?

Coronary cameral fistula is a rare congenital cardiac abnormality. An 18‐year‐old boy presented with features of right heart volume overload. Clinical examination was suggestive of hyperdynamic circulation with continuous murmur in precordium. 2D echocardiography showed dilated right coronary artery, and 3D echocardiography added information in tracing the track of the fistula which was consistent with the diagnosis of right coronary cameral fistula draining into the right ventricle. Coronary angiograms revealed an unusually dilated right coronary artery giving the appearance of an “elephant trunk” and with a fistulous tract into the right ventricle. Considering the higher risks of surgery in such difficult cases, we performed a successful transcatheter closure of the fistula using an Amplatzer vascular plug.     

Transcatheter closure of coronary artery fistulas

BACKGROUND: Transcatheter closure of coronary artery fistulas has emerged as a successful alternative to surgery. We describe various techniques and short-term findings in 15 patients who were taken up for transcatheter closure of these fistulas. METHODS AND RESULTS: Fifteen patients (aged 2-55 years; 12 males) with coronary artery fistulas underwent percutaneous transcatheter closure between June 1997 and December 2002. Site of origin of these fistulas were: right coronary artery in 7, left anterior descending coronary artery in 4, left main coronary artery in 2 and left circumflex coronary artery in 2 patients. Drainage site of these fistulas were: right ventricle in 9, right atrium in 4 and pulmonary artery in 2 patients. Out of these 15 fistulas, 14 were congenital and one was iatrogenically produced following inadvertent cutting balloon angioplasty of a septal perforator in a patient with chronic total occlusion of left anterior descending coronary artery. Various occlusion devices used to close these fistulas were: conventional metallic coils in 10, floppy tips of coronary angioplasty guidewires in 2, Amplatzer duct occluder in 1 and Amplatzer septal occluder in 2 patients. One of our patients had a coronary artery fistula draining by two openings into the right atrium, both of which were successfully closed using 2 Amplatzer duct occluders. Check angiogram after the procedure revealed complete occlusion in 13 (86.6%) and small residual flow in 2 patients. Follow-up studies at 3-55 months (mean 18 months) showed complete abolition of shunt in all patients with no evidence of recanalization leading to recurrence of shunt. CONCLUSION: Transcatheter closure of coronary artery fistulas is feasible and safe in the anatomically suitable vessels. Use of floppy tips of coronary angioplasty guidewires reduces the cost of the procedure significantly. which is an important consideration in developing countries like India.     

经导管法封堵冠状动脉瘘临床分析

目的:探讨经导管法封堵中老年冠状动脉瘘的技术方法、有效性及安全性。方法:将7例先天性冠状动脉瘘患者进行了经导管封堵治疗,选择性冠状动脉造影见冠状动脉肺动脉瘘3例,冠状动脉心房瘘3例,冠状动脉右心室瘘1例。标准冠状动脉介入方法将微导管定位于瘘管的中段,经该导管输送Cook弹簧圈用于封堵直径<8mm的瘘管;巨大瘘管(直径>8mm)采用Amplatzer动脉导管封堵器(ADO)封堵。如瘘管形态不适于行弹簧圈或ADO封堵,则采用带膜支架。结果:采用Cook弹簧圈栓塞3例,ADO封堵1例,带膜支架封堵2例,另1例冠状动脉导引导丝致瘘道夹层而自行堵闭。即刻冠状动脉造影微量残余分流2例,术后心电图无特殊改变,临床症状缓解,无手术死亡及并发症。随访4个月~2年,无不适症状。结论:经导管法封堵中老年人冠状动脉瘘创伤小,安全有效,可作为合适患者的首选方法。     

Transcatheter closure of muscular ventricular septal defect using the Amplatzer devices

TECHNIQUE: From November 1997 to June 2002, percutaneous transcatheter closure of muscular ventricular septal defects was attempted in seven patients. Four patients had single and three had multiple defects. Surgical closure was performed in two patients in an attempt to close a perimembranous defect, leaving behind a large apical muscular defect, which was successfully closed using a device in one patient, whilst the second patient succumbed to septicemia/endocarditis 3 weeks after failure of device implantation. One patient had previous pulmonary artery banding and in another intraoperative placement of two Clamshell devices followed by additional transcatheter closure using Gianturco coils in two different sessions was performed. RESULTS: Transcatheter closure of ventricular septal defect was successful in six patients. Three patients underwent closure of their ventricular septal defects using the Amplatzer Septal Occluder and in the remaining three patients. Amplatzer Muscular Ventricular Septal Defect Occluder was used. The median age was 15 months (range 14 months to 10 years) and the median weight was 7.8 kg (range 7-16 kg). The devices were deployed antegradely in all patients. Immediate complete closure was obtained in three patients while two patients had small and one had a large residual following the procedure. The later was due to another multiple muscular septal defect. Transient heart block occurred in one patient during the procedure and another patient developed heart block on day 3 post-procedure. The latter required temporary pacemaker. During the follow up, one patient who had residual multiple muscular defects underwent a successful redo transcatheter closure using two Amplatzer Muscular Ventricular Septal Occluder devices. CONCLUSIONS: We conclude that transcatheter closure of muscular ventricular septal defect using Amplatzer devices is feasible and effective.     

Management of coronary artery fistulae. Patient selection and results of transcatheter closure

OBJECTIVES: We report short-term findings in 33 patients after transcatheter closure (TCC) of coronary artery fistulae (CAF) and compare our results with those reported in the recent transcatheter and surgical literature. BACKGROUND: Transcatheter closure of CAF has been advocated as a minimally invasive alternative to surgery. METHODS: We reviewed all patients presenting with significant CAF between January 1988 and August 2000. Those with additional complex cardiac disease requiring surgical management were excluded. RESULTS: Of 39 patients considered for TCC, occlusion devices were placed in 33 patients (85%) at 35 procedures and included coils in 28, umbrella devices in 6 and a Grifka vascular occlusion device in 1. Post-deployment angiograms demonstrated complete occlusion in 19, trace in 11, or small residual flow in 5. Follow-up echocardiograms (median, 2.8 years) in 27 patients showed no flow in 22 or small residual flow in 5. Of the 6 patients without follow-up imaging, immediate post-deployment angiograms showed complete occlusion in 5 or small residual flow in 1. Thus, complete occlusion was accomplished in 27 patients (82%). Early complications included transient ST-T wave changes in 5, transient arrhythmias in 4 and single instances of distal coronary artery spasm, fistula dissection and unretrieved coil embolization. There were no deaths or long-term morbidity. Device placement was not attempted in 6 patients (15%), because of multiple fistula drainage sites in 4, extreme vessel tortuosity in 1 and an intracardiac hemangioma in 1. CONCLUSIONS: A comparison of our results with those in the recent transcatheter and surgical literature shows similar early effectiveness, morbidity and mortality. From data available, TCC of CAF is an acceptable alternative to surgery in most patients.     

High flow coronary fistula closure by percutaneous coil packing

Few cases of transcatheter coronary fistula closure have been reported. High flow coronary fistulae are usually treated by surgery. This case report presents a 5.4 liters/min flow coronary fistula percutaneously closed by steel coils. This large flow needed the packing of 25 coils, 10-15 cm long, for its total occlusion. © 1993 Wiley-Liss, Inc.     

经心导管法封堵冠状动脉瘘的临床分析

目的探讨经心导管法封堵先天性冠状动脉瘘的技术方法、疗效和安全性。方法对6例先天性冠状动脉瘘患者进行了经心导管法封堵治疗，其中男2例，女4例，年龄5—39岁(平均14．4岁)。选择性主动脉和冠状动脉造影见右冠状动脉右室瘘3例，右冠状动脉右房瘘1例，左冠状动脉右房瘘2例。结果采用pfm弹簧圈和COOK弹簧栓子堵塞3例，Amplatzer蘑菇伞封堵3例，均获成功。3例直接将封堵器封堵瘘口；另外3例用260cm交换导丝经导管通过瘘口至右心房，用网套导管套住交换导丝并拉出股静脉，送人传送器至瘘口上方，选择不同的封堵器封堵，观察心电图正常，重复主动脉造影或冠状动脉造影无分流后释放。结论冠状动脉瘘已往均采用外科手术修复，我们选用可控弹簧圈和Amplatzer蘑菇伞封堵获得成功，提示介入疗法具有较高的治愈性，操作安全，疗效可靠。     

Defect closure in the lipomatous hypertrophied atrial septum with the amplatzer muscular ventricular septal defect closure device: A case series

Variations in the anatomy of the atrial septum can confound the transcatheter closure of atrial septal defects and patent foramen ovale. While lipomatous hypertrophy of the atrial septum is not frequently encountered, attempts to use standard atrial septal occlusion devices in such patient can lead to malapposition and continued shunt. Some operators have suggested that atrial septal hypertrophy is a relative contraindication to transcatheter‐based closure techniques. We present a novel technique exploiting the features of the Amplatzer muscular ventricular septal defect occluder to treat atrial septal defects in the setting of lipomatous hypertrophy of the atrial septum in two patients. © 2011 Wiley‐Liss, Inc.     

Antegrade transcatheter closure of coronary artery fistulae using vascular occlusion devices

Two children (a 9 year old boy and a 2.5 year old girl) with coronary artery fistulae communicating with the right ventricle underwent successful transcatheter occlusion using an antegrade technique. A Rashkind double umbrella device was used in one case and an Amplatzer duct occluder in the other.


Keywords: interventional cardiology; congenital heart defects; coronary artery fistula; paediatric cardiology     

Outcomes of transcatheter embolization in the treatment of coronary artery fistulas.

Thirteen children (seven male) with coronary artery fistula underwent percutaneous transcatheter occlusion. The age range was 8 months to 14 years (mean, 6.3 years). The fistulas had their origins from the right coronary artery (six), from the left anterior descending coronary artery (three), and from the left circumflex coronary artery (four). Drainage was to the right ventricle (seven), the right atrium (three), and one each to the pulmonary artery, left atrium, and superior caval vein. The fistulas were closed with coils in 10 patients, a Rashkind double-umbrella device in 1 patient, and an Amplatzer Duct Occluder in 2 patients. Complete occlusion was achieved in 9 of 13 patients. Complications consisted of migration of coils in four and transient arrhythmias or changes in the resting electrocardiogram in four patients. Follow-up studies 1 to 31 months (mean, 14.6 months) after occlusion noted only four patients with trivial (clinically insignificant) residual shunts. Owing to various coronary fistula morphologies, transcatheter occlusion requires availability of different embolization techniques. Short-term follow-up supports persistent clinical efficacy and transcatheter closure techniques as the initial form of therapy.     

Percutaneous treatment of congenital coronary arteriovenous fistulas

Background: Congenital coronary arteriovenous fistulas (CAVF), although rare, can present as significant hemodynamic lesions necessitating intervention. Methods and results: Six patients (two males) with congenital coronary arteriovenous fistulas (CAVF) underwent percutaneous transcatheter occlusion. The ages ranged from 4 years to 49 years (mean 20.1 years). The fistulas had their origins from the right coronary artery (two), the left anterior descending coronary artery (two), and the left circumflex coronary artery (two). One of the fistulas drained to the right ventricle, four drained to the right atrium, and the remaining one to the left ventricle (LV). The fistulas were closed using the arterial approach with Cook? coils in two patients and with nitinol ductal occluders (NDOs) using the venous approach in four patients. One patient developed dissection of the wall of the fistula during attempted closure and had spontaneous occlusion of the fistula. Complete occlusion of the fistulas were achieved in all patients. Complications consisted of migration and embolization of the coils in one patient (later closed successfully with NDO) and myocardial infarction occurring two weeks following successful closure in another patient. At mean follow‐up of 39.6 +/? 22.9 months, all patients were asymptomatic and echo‐Doppler evaluation revealed no residual fistulae. Conclusions: CAVF are very well amenable to percutaneous closure with acceptable morbidity and high success rates. (J Interven Cardiol 2011;24:208–215)     

Transcatheter closure of secundum atrial septal defects with the new self-centering Amplatzer Septal Occluder.

AIMS: The study was set up to find out whether a new self-centering prosthesis for transcatheter closure of secundum atrial septal defects could overcome the disadvantages of previously described devices. METHODS AND RESULTS: Fifty-two consecutive patients with a significant atrial septal defect were considered for transcatheter closure with the Amplatzer Septal Occluder. The device, made of a Nitinol and polyester fabric mesh, provides a different approach to defect occlusion by stenting the atrial septal defect up to a stretched diameter of 26 mm. Three infants whose large defects were demonstrated on a transthoracic echocardiogram were excluded from transcatheter treatment. On transoesophageal echocardiography, 49 defects ranged from 6-26 mm, in one adult the defect measured 28 mm and this patient was excluded from attempted transcatheter closure. At cardiac catheterization in five further patients, devices were not implanted, in two because the stretched diameter exceeded 26 mm and in three the device was withdrawn because it was unstable or compromised the mitral valve. Thus, device closure was performed in 43 patients. At follow-up after 3 months the complete closure rate was 97%. CONCLUSION: The self-centering Amplatzer Septal Occluder is very efficient and user-friendly and offers interventional closure in 83% of an unselected group of patients presented with an atrial septal defect.     

Transcatheter occlusion of moderate to large patent arterial ducts, having a diameter above 2.5 mm, with the Amplatzer Duct Occluder. Comparisons with the Rashkind, buttoned devices, and coils in 116 consecutive patients

AIM: To report results of transcatheter occlusion of moderate to large patent arterial ducts, having a minimum diameter above 2.5 mm, with the Amplatzer duct occluder, and to compare these with results achieved using Rashkind or Sideris devices and Cook detachable coils. DESIGN AND SETTING: Retrospective study conducted on intention-to-treat data from a tertiary referral centre. PATIENTS: Since 1989, 116 consecutive patients, 77 females and 39 males, underwent percutaneous closure with several devices. We used the Rashkind double umbrella in 23 patients, the Sideris buttoned device in 39 patients, coils in 17 patients, and the Amplatzer duct occluder in 37 patients. The median age of the patients was 37 months, and the median weight 13 kg. The mean minimum diameter of the duct was 3.8 +/- 1.22 mm, with a median of 3.5 mm, and range from 2.5 to 10 mm. RESULTS: Implantation succeeded in all but 9 of the children (92%). The time of fluoroscopy was shorter, and full occlusion was better as judged on angiography, in patients closed using the Amplatzer device, despite closure of larger ducts, than in patients closed using other devices (p < 0.0001, p = 0.0003, and p = 0.0015 for the Rashkind, Sideris, and coils, respectively). Complications included embolisation in 2 patients, and haemolysis in 3 patients. In 12 patients, a second device was inserted because of residual shunting noted during follow-up. Complete occlusion was achieved earlier after implantation (p = 0.0002), and the rate of complete occlusion was better in patients receiving an Amplatzer device (97%, p = 0.024) than in patients undergoing closure with other devices. CONCLUSION: Transcatheter closure of moderate to large patent arterial ducts using the Amplatzer duct occluder is an effective and safe procedure, providing better results than those achieved using other occluders.     

冠状动脉瘘封堵技巧与效果

目的:冠状动脉瘘（coronary artery fistula,CAF）出口多变,形态多样,本研究探讨不同冠状动脉瘘的封堵技巧与封堵术治疗效果。方法:纳入1999年1月~2012年12月所有试图实施CAF封堵术的患者,在除外其它心脏畸形的基础上,根据主动脉或者冠状动脉造影观测CAF解剖形态,选择封堵术径路、封堵器类型和大小,封堵术后定期随访。结果:共纳入36例患者（男性17例）,年龄3至74 岁(中位数21岁)。CAF起源于左冠状动脉13例（36%）,右冠状动脉18例（50%）,双侧冠状动脉5例（14%）,引流至左心室7例（19%）,右心系统29例（81%）,包括右心房7例,右心室14例和肺动脉8例。成功封堵25例,成功率69%。经静脉途径封堵9例,CAF出口分别为右心房（n=5）,右心室（n=3）和肺动脉（n=1）;经动脉途径封堵16例,出口分别为左心室（n=3）, 右心房（n=1）,右心室(n=10)和肺动脉（n=2）。术后出现短暂胸痛2例,心电图ST T改变6例和再通1例。结论:介入方式治疗CAF安全、可靠,但具体采用何种径路和封堵器,需要根据其解剖形态确定。     

Perforation of the aorta after percutaneous closure of an atrial septal defect with an Amplatz prosthesis,presenting with acute severe hemolysis

We report a case of aortic perforation three weeks after transcatheter occlusion of an atrial septal defect (ASD) by an Amplatzer device. Revealed by acute hemolysis, this complication needed an emergency surgical operation. The fistula between the no coronary Valsalva sinus of the aorta and the left atrium was repaired. The ASD was closed by patch. This serious accident should consider a short antero-superior rim as a risk factor for aortic perforation in transcatheter closure for ASD.     

Successful occlusion of a coronary arteriovenous fistula using an Amplatzer duct occluder

In an 11-year old boy with a large coronary arteriovenous fistula between the left coronary artery and the right atrium, we achieved successful closure using a 10-8 Amplatzer Duct Occluder introduced from the right internal jugular vein. Angiography 6 weeks later showed complete occlusion of the fistula, with normal opacification of the left coronary arterial system. This technique may be used as an alternative to coils and surgery in selected patients.     

Transcatheter Closure of Coronary Artery Fistulae: Considerations and Approaches Based on Fistula Origin

Objectives

To investigate technical approaches for transcatheter closure of coronary artery fistula based on anatomic type of the fistula.

Background

The variability in coronary artery fistulae (CAF) anatomy that necessitates different transcatheter closure (TCC) approaches has not been well documented.

Methods

Records of patients with CAF who underwent TCC at 2 centers were reviewed for technical details and procedural outcome. CAF were classified as proximal and distal. TCC approaches employed were arterio‐venous or arterio‐arterial loop, retrograde arterial, and antegrade venous.

Results

Eighteen patients with CAF, mean age 12.6 years (0.07–60), 11 male (61%), underwent TCC. All CAF drained predominantly into the right side of the heart. Types of CAF were proximal in 15 and distal in 3 patients. CAF calibers were large in 7, medium in 9, and small in 2 patients. The arterio‐venous loop approach was used in the majority of the cases (11 patients) and the CAF size were medium to large. The retrograde arterial approach was used in 4; of these, 3 patients had small to medium sized CAF. In 2 patients with long tortuous CAF an antegrade venous approach was employed. TCC was successful in 17 of the 18 patients (94.4%). There were no peri‐procedural deaths or vascular complications.

Conclusions

This study documents transcatheter closure approaches for CAF and device selection based on fistula origin. The choices of TCC technique and device selection vary, and are primarily determined by the heterogeneous anatomic characteristics of the fistulae.