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Percutaneous Treatment of Coronary Artery Fistula

Incidence and etiology of Coronary artery fistula

Coronary artery fistula (CAF) is a rare coronary artery anomaly characterized by aberrant communications between coronary arteries and cardiac chambers, pulmonary artery, pulmonary vein, coronary sinus or vena cava. The reported incidence of CAF in patients undergoing catheterization examination is 0.1% to 0.2%. The cause of CAF are mostly congenital, the others are traumatic and iatrogenic. For those with congenital CAF, symptoms or complications often appear during or after the second decade of life, however, asymptomatic patients still comprise about half of this group.

Therapeutic option for Coronary artery fistula

In a recent review, Amsby, et al reported that the procedural success rate was 83% and 91% of patients maintained a state of complete closure during long-term follow-up. Although transcatheter occlusion has been advocated as a minimally invasive alternative for CAF, it is by no means without risk. Reported complications include transient electocardiographic changes, myocardial infartion, fistula dissection, pulmonary or epicardial coronary artery embolization.

The appearance of graft stent further diversified the treatment strategies for this disease entity. Graft stent, initially used in peripheral intervention, was introduced to coronary artery tree for its effectiveness in some bail-out situations such as vessel perforation, and recently, there is a trend to extend its indications. However, the application of graft stent to close CAF is limited and only can be seen in few case reports. In our case, the graft stent we used is JOSTENT® Coronary Stent Graft Supreme System which has balloon-expandable, biocompatible PTFE graft material sandwiched between two stainless steel stents. In previous two studies, Graft Jostent had been tested in various clinical settings of coronary artery disease, the primary success rate is high, achieving 95.9% in one series, and with procedural safety. However, the long-term follow-up results in native coronary artery lesions are somewhat disappointing. The restenosis rate of covered stent is not superior to conventional noncovered stent, probably because its failure to limit neointimal hyperplasia at stent edges. The complications of implantation mainly include side-branch occlusion and relatively higher incidence of stent thromosis. The former is an important limitation of the covered stent when used in native coronary artery, which usually cause non-Q-wave myocardial infarction and even acute Q-wave infartion if a large side branch is closed. The latter might attribute to the delayed endothelialization of stent surface which warrants an intensive antiplatelet regimen. For the special design of covered stent, meticulosity is required in selecting patients. The coronary anatomy of our patient is suitable to covered stent therapy, because there is no big side branch adjacent to the CAF, and the treated site lies in proximal LAD without tortuous segments prior to it, which otherwise might prevent the relatively bulky stent from arriving at the target. Furthermore, the stenosis around the originating site of fistula, which is considered to enhance the coronary steal phenomenon, can be treated simultaneously without additional manipulation and devices. Compared with coil embolization, using graft stent to treat CAF is of technical ease and time-saving, without the need to cannulate and wire the fistula, no concern about multiple drainage sites, tortuosity of the feeding vessel, angulation of the fistula ostium and pulmonary artery embolization. For an experienced coronary interventionist, there is nearly no difference from the conventional stent implatation technique, so that specific training process is avoided.

References

  1. Dorros G, Thota V, Ramireddy K, Joseph G. Catheter-based techniques for closure of coronary fistulae. Cathet Cardiovasc Intervent 1999;46:143-150.
  2. 2. 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;39:1026-1032.
  3. 3. Gercken U, Lansky AJ, Buellesfeld L, Desai K, Badereldin M, Mueller R, Selbach G, Leon MB, Grube E. Results of the Jostent coronary stent graft implantation in various clinical settings: procedural and follow-up results. Cathet Cardiovasc Intervent 2002;56:353-360.
  4. 4. Mullasari AS, Umesan CV, Kumar KJ. Transcatheter closure of coronary artery to pulmonary artery fistula using covered stents. Heart 2002;87:60.

Fuente: Angioplasty SummitM.D Focus review

Ultima actualizacion:16 de Diciembre de 2006

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