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Relevant clinical history and physical exam
A 46 year-old female patient was transferred from local hospital because of abnormal ECG findings and effort related chest discomfort. She had no significant cardiovascular risk factors such as diabetes or hypertension. She told that seventeen years ago, she had been suffered from chest discomfort and dyspnea from a large coronary artery fistula (CAF) and treated by surgical ligation at another hospital. She had no illness comparable to Kawasaki disease.
Relevant test results prior to catheterization
Coronary CT angiography showed large, aneurysmal cononary fistula between left main and entire course of anatomical LCX and draining into left ventricule (LV). The fistula showed short segmental stenosis with surgical materials because of incomplete surgical ligation. Distal LCX drained into LV directly and the LCX territory of LV supplied from collateral circulation from RCA and diagonal artery.
Relevant catheterization findings
Coronary angiography revealed the similar findings to CT results. There was no significant stenosis in RCA and LAD, however, the distal flow of LAD was slightly slow (TIMI 2-3 flow).
She wanted to occlude the fistula completely without open heart surgery. After review of the CT angiography and coronary angiography, we decided to perform transcatheter embolization with Ampltzer Vascular Plug (AVP). A 6Fr sheath was inserted through right radial artery and the left coronary artery was engaged with a 6Fr JL4 guiding catheter (Cordis). We inserted a coronary guide wire (Run through, Terumo) into the fistula and passed the narrowed portion and performed intravascular ultrasonography (IVUS) evaluation for precise assessment about the fistulous tract. At the narrowest segments except ligated portion, which was located at the just proximal to the incompletely ligated portion, vessel diameter was about 10.2 mm by IVUS measurement. A 6F JR catheter was inserted within the fistula deeply for better backup support, and was then placed with its tip at the proximal of the narrowest portion, a 12 mm Amplatzer Vascular Plug 2 (AVP 2) loaded and delivered into the fistula. Afterwards, the plug was released from the cable. Selective angiography by means of a guiding catheter 5 minutes after deployment of AVP 2, revealed complete occlusion of the fistula at plug level and distal LAD flow was good (Figures 1 and 2). After discharge, single antiplatelet agents were continued and the patient is asymptomatic. Three month later, we performed a follow-up coronary CT angiography, which revealed the aneurysmal CAF were completely occluded. (Figure 3).
In comparison with many other devices, the AVP affords several advantages, including ease of delivery, a wide range of device sizes, and the opportunity to reposition the device safely during and after initial deployment. Our case is of particular interest, the fistula was partially ligated and has very large reference diameter. We completely occluded the incompletely ligated fistula with carefully selected vascular plug. Optimal result of our case suggests that it is feasible and safe to apply an AVP for transcatheter occlusion of large coronary artery fistula.