Novel treatment of coronary artery fistulae concealing severe coronary artery lesion: using thrombus aspiration catheter as a delivery guide
A 83 years old man with diagnosis of unstable angina pectoris who underwent coronary angiography in a different hospital was refered to us for occlusion of CFA originating from left anterior descending (LAD) and empting to the pulmonary artery. He had huge CAF () and subtotal stenosis of mid right coronary artery (RCA) lesion ().\nDecision of closure of fistulae with amplatzer vascular plug 4 and stenting of right coronary artery mid lesion was taken. At first, we aimed to treat mid RCA lesion. During the engagement of RCA ostium, another fistulae was detected (). It was originating from right sinus valsavla and most likely communicating to pulmonary artery. Then, we engaged left coronary artery ostium with 7F Judkings guiding catheter. Sequential and simultaneous contrast injection demonstrated that both of fistulae were openning to the pulmonary artery at the same place (). We decided to occlude left sided CAF at first. Vigorous attempts were done to proceed multi-purpose and right Judkings catheter through fistulae. But we could not succeed. Then, we decided to use thrombus aspiration catheter (TAC) as a delivery guide. After wiring the fistula with the 0.014-inch guidewire, TAC was advanced over the guidewire. After the optimal position of aspiration catheter was obtained (), amplatzer vascular plug (AVP) was loaded into the aspiration cathater and advanced carefully. After the optimal device position was assured, vascular plug was released and control image demonstrated completely closure of fistulae and significant LAD stenosis just distal to the origin of fistulae that was not seen in previous coronary angiography (, ). We gave nitroglycerine in order to be sure that this image was not due to the spasm. There was no effect of nitroglyserine and lesion was stented with 3.5 mm × 15 mm bare metal stent and postdilated with 4 mm × 12 mm noncompliant balloon. Final image was satisfactory. Because of high dose use of contrast media (about 300 mL) and patient renal function (creatine was 1.6), the other CAF was untreated.\nAfter a month later, patient was taken to the catheter laboratory for occlusion of second coronary to pulmonary artery fistulae. Control image demonstrated patent LAD stent and occluded fistulae (). Vascular plug 2 was loaded in guiding catheter and was advanced as further as possible. After confirming the correct positon of device (), it was released. Control image demonstrated totally occlusion of fistulae ().