Successful percutaneous closure of a tortuous coronary artery to pulmonary artery fistula using the anchor technique: a different approach

Introduction

Coronary artery fistula (CAF) is described as an anomalous connection between a coronary artery and a major vessel or cardiac chamber. It can result in myocardial ischemia, heart failure, pulmonary hypertension, bacterial endocarditis, and rupture of aneurysmal vessels [1]. The majority of these fistulae originate from the left anterior descending artery or from the right coronary artery [2]. Symptomatic coronary artery fistulae are usually treated with percutaneous intervention or surgical correction [3]. We report herein a case of successfully performed percutaneous coil embolization of a tortuous coronary artery fistula using the anchor technique.

Case report

A 60-year-old man was examined for retrosternal pain radiating to the left upper limb. The electrocardiogram showed normal sinus rhythm. The transthoracic echocardiogram demonstrated a normal left ventricular size and mild concentric left ventricular hypertrophy with abnormal regional wall motion in the inferior segment. A myocardial perfusion scintigraphy test was performed, revealing mild reversible inferior ischemia. Six months before, this patient had come with the same complaints, and percutaneous coronary intervention was performed on the right coronary artery (RCA) due to a critical lesion; also coronary fistula originating from the proximal portion of the circumflex artery to the pulmonary artery (Figure 1 A) was observed, but it was not planned to intervene.
This time, diagnostic coronary angiography was performed again; it revealed no significant atherosclerotic stenosis and a patent stent in the RCA, and the fistula was seen again. The fistula was relatively large, with an approximate diameter of 2.8 mm.
We inferred that the angina and inferior ischemia revealed by myocardial perfusion scintigraphy occurred due to the fistula and coronary artery steal. Therefore, we planned to perform percutaneous coil embolization of the fistula.
A 7-Fr EBU 4.5 coronary guiding catheter (Launcher, Medtronic, Minneapolis, MN, USA) was inserted into the right femoral artery and engaged in the left coronary artery. During the procedure, 7000 U of heparin (at a dose of 100 U/kg) were administered intravenously. We initially planned to introduce the guidewire distally to the fistula and scroll a microcatheter through a guidewire to perform coil embolization. A 0.014-inch guidewire (Regalia XS, Asahi Intecc, Aichi, Japan) was inserted into the fistula....


View full text...