Tough Calls: Case 4

Large Coronary Fistula After Sudden Death

Imagine how you would work through each case. What equipment would you select and what would you do first? After having a go at it, see what our panel would do in the same situation. This exercise highlights the many possible approaches to a difficult problem. By seeing what others would do after thinking it through yourself, you will gain an understanding of the spectrum of approaches to a problem. 

37 year old gentlemen; out of hospital cardiac arrest, inducible VT, severe TR. Coronary angiography demonstrates a giant coronary fistula to the RA. The fistula outlet measures approx. 7 mm on balloon occlusion angiogram.

Expert Approaches

Hover over an experts image to view their approach.

  • I would aim to close this in a retrograde fashion (i.e. from venous side)

  • Aim to use AVP2 device (10-12mm diameter most likely). Alternative is AVP4 device which can go through any catheter with 0.035" lumen but largest device 8mm which may not be large enough to occlude this fistula.

  • Deliver device from RFV using Agilis sheath and 6F MP guide (for AVP2) 

  • Create AV rail as in picture to deliver guide from venous side to proximal aspect (coronary side) of fistula - aim to position as close to proximal end as possible (ie minimizing length of residual fistula in connection with coronaries that may embolise thrombus proximally but not jailing LCx branches). 

  • I would anticoagulate post closure.

Dr. William Wilson
MBBS, PhD, FACC
 
Consultant Cardiologist at Royal Melbourne Hospital
  • Giant coronary fistula

  • Would approach this case antegrade

  • 90cm EBU guide

  • 0.014” workhorse coronary wire down fistula

  • Telescope 100cm 5Fr Bernstein catheter over wire into fistula

  • 8mm AVP2 through Bernstein deployed in the proximal segment of fistula

  • Angio, if significant leak, telescope guide into fistula and remove 8mm device and Bernstein and upsize to 10mm AVP II.  Alternatively, if 8mm device stable with eccentric leak around, could deploy coils to seal residual communication

  • Consideration for short term systemic anticoagulation to avoid rapid

  • Thrombus formation and extension into main coronary branch.

Dr.John Carroll
MD, FACC, MSCAI
 
Professor of Medicine, University of Colorado Denver
Director of Interventional Cardiology

Couple of techniques: 1. cross from coronary to RA, snare, establish loop, then from femoral vein advance sheath to coronary artery via fistula. Then place a PDA10-8mm or VSD device 8mm. Alternatively, my preferred approach: engage with a guide catheter, then advance a microcatheter for coiling: these are the best microcatheters: Excelsior SL-10 and 10-18 (Stryker, Kalamazoo, MI, USA), Echelon 10 and 14 (Medtronic, Minneapolis, MN, USA) and Headway 17 (Microvention TERUMO, Tustin, CA, USA). Use Target detachable coils, here I would use 10mm diameter by 20-30cm long.

Dr. Ziyad Hijazi
Professor of Pediatrics & Medicine, Weill Cornell Medicine
Chair, Department of Pediatrics and Director, Sidra Cardiac Program

 

•Retrograde angiography from aorta/LMCA

•A-V wire loop as noted and then bring sheath prograde from femoral vein up to the most proximal aspect of the fistula

•AVP II (probably 10-12mm) at the proximal end with consideration for a second device at the end of the fistula near the connection to the RA as the sheath is removed

•Careful device positioning essential to avoid normal coronary artery side branch occlusion

Dr. Matthew Crystal
MD, FACC, FSCAI
 
New York-Presbyterian & Morgan Stanley Children's Hospital
Assistant Professor of Pediatrics, Columbia University Medical Centre

•Close the fistula as proximal as possible

•AVP II 14 mm

•Antiplatelet and anti coagulant therapy

Dr. Zahid Amin
MD, FSCAI, FAHA, FAAP
 
William B. Strong Chair & Professor & Section Chief Division of Pediatric Cardiology
Children's Hospital of Georgia, Augusta University

•Close with 12 mm AVP-II just beyond takeoff of the “normal” coronary artery, approached from CS end. 

•Place 2nd device proximal to the 1st if incomplete closure

•Anticoagulation +/- aspirin for 3-6 months

MD, FSCAI
 
Dr. Nathan Taggart

Pediatric Interventional Cardiologist 
Assistant Professor of Pediatrics
Mayo Clinic