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TRANSCATHETER CLOSURE OF CORONARY ARTERY FISTULA DR DO NGUYEN TIN DAO ANH QUOC, MD CHILDREN HOSPITAL 1, HCMC AIM • Describe the techniques used in transcatheter closure of coronary artery fistula • Report our results with this procedure • Compare our findings with those described in the transcatheter and recent surgical literature INTRODUCTION • Abnormal connection between one of the coronary arteries and a heart chamber or another blood vessel • Rare anomalies 0.002% population, 0.4% cardiac malformations • Congenital or acquired • Continuous murmur HISTORY • • • • • The first described by Krause 1865 Abbott: morphology of fistula 1906 Bjork and Crafoord: surgical closure 1947 Haller and Little: angiography for surgery 1963 Reidy: successful percutaneous closure 1983 MORPHOLOGY • Origination: – RCA: 50% to 60% – LAD: 25% to 42% – Cx : 18.3% – Single fistulas :74% to 90% – Multiple fistulas occur in 10.7% to 16% • Drainage – PA 15% to 43% – RV 14% to 40% – RA 19% to 26% – LV 2% to 19% – LA 5% to 6% Our series • Origination : – RCA : 67% (10/15) – LCA : 27% (4/15) – both coronary arteries : 7% (1/15) • Drainage : – – – – – RV : 53% (8/15) RA : 20% (3/15) LA : 13% (2/15) LV : 6,7% (1/15) Complex fistula : 6,7% (1/15) RCA to LA LCA to RA RCA to RV Retrograde with plug Retrograde with ADOI Retrograde with VSD muscular Retrograde with ADOII Antegrade with plug Antegrde with coils Antegrade with coils in complex RESULTS • Immediate results • Complete occlusion: cases • Residual shunt: 10 cases • Non intervention : cases • Coronary branches appear again • Balloon test for evidence of ischemia: we kept the device at least 30 minutes before release to check myocardial ischemia • Short- term and long- term results • Complete occlusion: 77% (10/13) • Residual shunt : 15% (2/13) • Shunt RV- aneurysm: case • Short- term and long- term results • No major complication recorded • No vascular injury • No myocardial infarction • Occlusion some small branches • Arrhythmia: case with VPC • Heart failure: case due to long term myocardial ischemia DISCUSSION • THE SITE to occlude the fistulous artery:  As distally as possible or  As close to its termination point as possible,  Avoiding any possibility of occluding branches to the normal myocardium • BUT, NO embolization beyond the fistula • Occlusion is effected at a very precise point • Antegrade or retrograde approach  Advantages of retrograde approach Bigger size of devices can be used Avoid coronary damages  Advantages of antegrade Easier to reach the lesions Choose the right position to occlude CONSIDERATIONS IN PEDIATRIC • Age of the patient  Small vessels, small catheters but big fistula and big devices  Small aorta: difficult to coronary angiography  Small amount of contrast  The smaller heart size, the more tortouos fistula CONCLUSION Excellent results can be achieved by the transcatheter embolization techniques to treat coronary artery fistulas Difficult in technique: small vessels and tortouos It is vital to select suitable device for the size and location of the fistula Nowadays, no patient should be referred for surgical ligation unless transcatheter closure has been considered