Percutaneous Hydrogel Coil Embolization of Aneurysms and Coronary Artery Fistulae in Congenital Heart Disease.

Patients with congenital heart disease frequently have aneurysms or coronary artery fistulae that necessitate treatment. Metal vascular coils have been a mainstay of treatment for these lesions. In 2002, coils coated or filled with expandable hydrogel were introduced to treat cerebral aneurysms; however, the literature on their use in patients with congenital heart disease is limited. We present 5 cases in which large vascular lesions in children or adolescents with congenital heart disease were successfully occluded with hydrogel coils.

Transcatheter Coil Embolization in 17 Patients with 22 Coronary Artery Fistulas.

Coronary artery fistulas are rare anomalies that often become symptomatic with age. They are typically diagnosed incidentally during coronary angiography. The chief nonsurgical treatment is transcatheter coil embolization. We evaluated the outcomes of this procedure in 17 symptomatic patients who had 22 fistulas in total. The 9 men and 8 women (mean age, 52 ± 16.5 yr; range, 27-74 yr) presented at 4 Turkish hospitals from October 2008 through March 2015. Three patients had multiple fistulas. Twelve fistulas originated from the right coronary artery and 10 from the left coronary artery, draining into the pulmonary artery in 18 instances. We evaluated results postprocedurally and after 2 to 5 months, defining angiographic success as a flow better than Thrombolysis in Myocardial Infarction grade 2 in the treated artery. Twenty-one of the 22 procedures immediately produced the targeted flow. We observed 2 minor and no major complications. On follow-up, 3 symptomatic patients underwent successful repeat treatment of one fistula each. We found that transcatheter coil embolization afforded good success rates with few complications in closing coronary artery fistulas. We share our experience to add to the data on treating patients with coronary artery fistulas, and to raise awareness among clinicians.

Unusual Complication of the Nuss Procedure: Fistulization of the Internal Thoracic Artery to the Pulmonary Artery.

Although minimally invasive repair of pectus excavatum has been shown to have a low complication rate in large series, several case reports have documented life-threatening complications, including bleeding and cardiac perforation. We present a rare case of an arteriovenous malformation from the internal thoracic artery to the pulmonary artery caused by occlusion of the internal thoracic artery by the Nuss bar followed by an unidentified angiogenic process. The patient became symptomatic and required transcatheter coil embolization.

A Rare Cause of Angina After Coronary Bypass Grafting; Left Internal Mammary Artery to Pulmonary Artery Fistula and Successful Treatment with Transcatheter Coil Embolization.

Fistula from left internal mammary artery (LIMA) to pulmonary artery (PA) is rarely encountered in daily practice. In recent years, endovascular therapy options have emerged for the treatment of fistula formations and replaced with surgery. A 53-year-old man admitted to our outpatient clinic with symptoms of typical angina and shortness of breath despite optimal medical therapy. In his relevant history, he had a coronary artery bypass graft (CABG) operation in 2009 in which his LIMA was anastomosed to left anterior descending (LAD) and ramus artery sequentially. Coronary angiography including selective imaging of LIMA demonstrated a fistula formation originating from the proximal portion of the LIMA and draining to PA. After successful closure of fistula with transcatheter coil embolization, the patient was discharged without any complication and symptom. In conclusion, although LIMA to PA fistula is an infrequent clinical condition, it should be considered as a potential cause of persistent angina after CABG operation. Treatment options include conservative medical therapy, surgical ligation and endovascular interventions. The best therapy should be individualised for each patient in respect to patient's symptoms, surgical compatibility and anatomy of fistula.

A Rare Cause of Angina After Coronary Bypass Grafting; Left İnternal Mammary Artery to Pulmonary Artery Fistula and Successful Treatment with Transcatheter Coil Embolization / Uma Causa Rara de Angina Após Revascularização do Miocárdio: Fístula da Artéria Mamária Interna Esquerda para Artéria Pulmonar e Tratamento Bem-Sucedido com Embolização Transcateter com Molas

Abstract Fistula from left internal mammary artery (LIMA) to pulmonary artery (PA) is rarely encountered in daily practice. In recent years, endovascular therapy options have emerged for the treatment of fistula formations and replaced with surgery. A 53-year-old man admitted to our outpatient clinic with symptoms of typical angina and shortness of breath despite optimal medical therapy. In his relevant history, he had a coronary artery bypass graft (CABG) operation in 2009 in which his LIMA was anastomosed to left anterior descending (LAD) and ramus artery sequentially. Coronary angiography including selective imaging of LIMA demonstrated a fistula formation originating from the proximal portion of the LIMA and draining to PA. After successful closure of fistula with transcatheter coil embolization, the patient was discharged without any complication and symptom. In conclusion, although LIMA to PA fistula is an infrequent clinical condition, it should be considered as a potential cause of persistent angina after CABG operation. Treatment options include conservative medical therapy, surgical ligation and endovascular interventions. The best therapy should be individualised for each patient in respect to patient's symptoms, surgical compatibility and anatomy of fistula.

Resumo A fístula da artéria mamária interna esquerda (AMIE) para a artéria pulmonar (AP) é raramente encontrada na prática diária. Nos últimos anos, opções de terapia endovascular surgiram para o tratamento de formações de fístula e foram substituídas por cirurgia. Um homem de 53 anos de idade, internado em nosso ambulatório com sintomas de angina típica e falta de ar, apesar da terapia clínica ideal. Em seu histórico relevante, ele teve uma cirurgia de revascularização miocárdica (CRM) em 2009, na qual sua AMIE foi anastomosada à descendente anterior esquerda (DAE) e à artéria ramus sequencialmente. A angiografia coronária, incluindo imagens seletivas da AMIE, demonstrou uma formação de fístula proveniente da porção proximal da AMIE e drenando para AP. Após o fechamento bem-sucedido da fístula com embolização transcateter com mola, o paciente recebeu alta sem qualquer complicação e sintoma. Em conclusão, embora fístula entre AMIE e AP seja uma condição clínica pouco frequente, deve ser considerada como uma causa potencial de angina persistente após a operação de revascularização do miocárdio. As opções de tratamento incluem terapia médica conservadora, ligadura cirúrgica e intervenções endovasculares. A melhor terapia deve ser individualizada para cada paciente em relação aos sintomas do paciente, compatibilidade cirúrgica e anatomia da fístula.

Transcatheter embolization of systemic-to-pulmonary artery fistulas in a dog using embolization coils and silk suture.

A 4-month-old intact female Cavalier King Charles spaniel presented for evaluation of a left, basilar continuous murmur. Transthoracic echocardiography suggested anomalous vessels around the main pulmonary artery, and computed tomography angiography revealed two systemic-to-pulmonary artery fistulas. Transcatheter embolization of these fistulas was achieved with a combination of embolization coils and silk suture threads delivered through a microcatheter.

Left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome: A review of literature on therapy, intervention, and management.

Coronary artery anomalies (CAA) are anatomical aberrations in the origin, structure, and course of the epicardial arteries. Literature has detailed common anomalies or fistulas formed because of coronary artery bypass grafting (CABG) manipulation of intrathoracic vessels. Despite the commonality of the CABG procedure, there are a few CAA and fistula findings which remain extremely rare. We present a case of left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome that presented symptomatically as a malignant arrhythmia. Following a literature review of therapy, intervention, and management we recommend a team based approach when faced with this extremely rare case presentation. The goal of management should to reduce symptoms, and ischemia, by reducing or stopping flow through the fistula and out of the coronary blood supply.

[Coronary Artery to Pulmonary Artery Fistula with a Large Coronary Artery Aneurysm Detected by Multi-detector Row Computed Tomography;Report of a Case].

We report a case of coronary artery to pulmonary artery fistula with a large coronary artery aneurysm (80 mm). A 62-year-old man was referred to our hospital because of syncope without heart failure. Electrocardiogram abnormality and asynergy in the anteroseptal wall were detected on echocardiography. Coronary angiography and multi-detector row computed tomography( MDCT) showed a large coronary artery aneurysm and coronary artery to pulmonary artery fistula originating from the right coronary artery( RCA), left main trunk( LMT) and left anterior descending artery( LAD). The fistula was treated using ligation and endocardial closure, and the aneurysm was resected without coronary artery bypass grafting. Postoperatively, MDCT showed that the fistula and aneurysm had disappeared. MDCT was useful for understanding the spatial relation of the coronary artery to pulmonary artery fistula.

Exercise-induced ventricular arrhythmia due to bilateral coronary to pulmonary artery fistulas.

Ischemic polymorphic ventricular ectopy was documented during exercise testing in a 65-year-old Caucasian male patient. Coronary angiogram revealed four coronary to pulmonary artery fistulas (CPAFs) originating from the right and left coronary artery, leading to myocardial ischemia due to steal phenomenon. The three dominant fistulas were coiled percutaneously, while one small fistula was left untreated. During follow-up, no significant residual ventricular arrhythmia was detected.

Where is the Origin of the Last Normal Branch from Feeding Artery of Pulmonary Arteriovenous Malformations?

PURPOSE: Reperfusion via pulmonary-to-pulmonary arterial anastomoses is known as one type of recurrence of pulmonary arteriovenous malformations (PAVMs) after embolization. It is important to occlude the fistulous portion beyond the origin of the last normal branch from feeding artery of PAVMs to prevent recurrence. In this study, we evaluate the origin of the last normal branch by CT as well as its visibility on pulmonary arteriography (PAG). MATERIALS AND METHODS: We reviewed forty patients with 77 PAVMs who underwent coil embolization between October 2007 and December 2017. All patients underwent MDCT before embolization. Axial and MPR CT lung images were reviewed with special interests in the origin of the last normal branch from feeding artery of PAVMs. The origin was classified into three portions, including sac, junction (portion just proximal to the sac) and proximal feeder (more than 5 mm proximal to the sac). We also evaluated whether PAG can depict the normal branches detected by MDCT. RESULTS: MDCT showed that the last normal branch originated from sac in 30 PAVMs (39.0%), junction in 39 (50.6%), and proximal feeder in 8 (10.4%).On selective PAG, the last normal branch could be visualized in 30 PAVMs (39.0%), although it could not be visualized due to high-flow shunt in the other 47 PAVMs. CONCLUSIONS: Selective PAG frequently fails to demonstrate the last normal branch from feeding artery of PAVMs, which often originates from the sac. Pretherapeutic evaluation of CT images of the last normal branch is important to prevent reperfusion of PAVMs. LEVEL OF EVIDENCE: Level 3, local non-random sample.

Embolization of a complex coronary to pulmonary artery fistula using balloon assisted liquid embolic injection: A novel technique.

Complex Coronary artery to Pulmonary artery fistulas (CPFs) can be difficult to manage with embolization or ligation. An 88-year-old woman with exertional angina was found to have a complex precordial CPF, severe Mitral regurgitation, and Pulmonary Hypertension. CPF treatment was recommended prior to minimally invasive mitral valve replacement (to avoid postoperative myocardial ischemia from worsened steal). The CPF was supplied by multiple branches from the LAD and RCA, and formed a complex common varicosity with multiple drainage channels to the pulmonary artery. The CPF was treated by injecting a liquid embolic agent, Ethylene Vinyl Alcohol Copolymer (Onyx, Medtronic, MN), into two of the feeding arteries arising from the RCA through a Scepter C Dual lumen balloon micro catheter (Microvention, Aliso Viejo, CA. This resulted in complete obliteration of the fistula, and the patient subsequently underwent successful mitral valve replacement surgery.

Endovascular Embolization of Coronary Artery-Pulmonary Artery Fistulas with Double Coronary Aneurysms.

A 75-year-old woman with chest discomfort and a continuous murmur was admitted to our hospital. During noninvasive examination, computed tomography angiography showed a coronary artery-pulmonary artery fistula with double giant coronary aneurysms (one was 42 mm× 32 mm× 32 mm, and the other was 25 mm× 20 mm× 17 mm) arising from the proximal part of the left anterior descending (LAD) artery. Stress myocardial scintigraphy showed ischemia at the LAD area. Given her frailty, the heart team, including cardiac surgeons, judged that surgical treatment would be difficult. Thus, endovascular embolization for the abnormal vessels was selected. After coronary angiography, two coronary aneurysms were embolized by 53 coils, and the feeding artery was embolized by two coils and one Amplatzer Vascular Plug 4™. A small pulmonary artery fistula remained after the procedures; thus, additional embolization was performed 3 months after the index procedure. Thereafter, angiography showed no flow into the aneurysms, and her symptoms improved.Endovascular embolization might be an effective treatment to achieve aneurysm occlusion in patients at high risk for surgical treatment. Although the present case had double coronary aneurysms with a large feeder vessel, the combination procedure of coils and vascular plug was able to embolize this abnormal vessel.