Successful Concomitant Treatment of a Coronary-to-Pulmonary Artery Fistula and a Left Anterior Descending Artery Stenosis Using a Single Covered Stent Graft: A Case Report and Literature Review

Successful Concomitant Treatment of a Coronary-to-PulmonaryArtery Fistula and a Left Anterior Descending Artery Stenosis Using a Single Covered Stent Graft: A Case Report and Literature Review zyxwvutsrqp zyxwvutsrqpon SERBAN BALANESCU, M.D., GIUSEPPE SANGIORGI, M.D., MASSIMO MEDDA, M.D., YUNDAI CHEN, M.D., SERENELLA CASTELVECCHIO, M.D., and LUIGI INGLESE, M.D. zyxwvut From the Cardiac Catheterization Laboratory, Istituto Policlinico San Donato, San Donato Milanese, Milan, Italy This report describes a case of a 47-year-old man who presented with early post-Q wave myocardial infarction angina and an atherosclerotic 1eB anterior descending stenosis associated to a coronary-to-pulmonary artery fistula. Both coronary stenosis and fistula were successfully treated with a single polytetrafluoroethylene-covered stent grafl implantation by intravascular ultrasound-guidedprocedure. (J Interven Cardiol2002; 15209-214) Introduction Coronary artery fistulas are rare vascular anomalies that establish an abnormal communication between a large epicardial artery and any cardiac chamber (most frequently the ventricles) or a large cardiac vessel, like the coronary sinus or the pulmonary artery. Their origin is mostly congenital,’ but they may be occasionally found after cardiac trauma or after chest irradiation for therapeutic purposes.2 The first description of a coronary fistula was published in 18653 and since then, an ever-increasing number of cases have been described. Their prevalence in patients submitted to coronary angiography is low, between 0.2% and 0.25%? Although almost equally distributed in frequency between right and left coronary arteries, fistulas originating in the right coronary are slightly more frequent as those originating in the left coronary artery.’ Bilateral fistulas have been identified in 4 5 % of all coronary fistula case^.^.^ Most of the patients with coronary fistulas are asymptomatic and the anomaly is incidentally found at coronary angiography. The most common clinical presentation is that of a continuous heart murmur. They may have abnormal findings on standard electrocardiogram (ECG) or on chest X ray despite complete lack of ~ymptorns.~ However, patients may become symptomatic with advancing age, mainly depending on the severity of the pulmonary-to-systemic flow rati^.^ Serious complications have been described, like congestive heart failure, infectious endocarditis,’ arrhythmia~,~ and pulmonary hypertension. lo In addition, there is a demonstrated relation between coronary fistulas and the occurrence of myocardial ischemia. This is currently explained by a “coronary steal syndrome” that occurs because of flow shunting over the fistula.”*’2Ischemia may occur even in the absence of atherosclerotic coronary artery disease. l 3 Occasionally a coronary fistula may coexist with an atherosclerotic coronary stenosis. l4 Since spontaneous fistula closure is infrequent and long-term complications may be serious, some investigators suggested elective surgical ligation even in asymptomatic patient^.'.'^.'^ In the last few years, some percutaneous catheter devices have been designed to close such fistulas.17-20 Covered stent grafts may represent an alternative technique for closure of coronary fistulas. They have been designed to overcome some limitations of conventional stenting, like plaque protrusion through stent struts and plaque embolization.2’*22 Coronary artery rupture and aneurysms have also been treated with covered stents, avoiding the necessity of cardiac s ~ r g e r y . ~ ~ , ’ ~ zyxwvut zyxwvu Address for reprints: Serban Balanescu, M.D., Laboratorio di Emodinamica, Istituto Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy. Fax: +39-02-5277458s; e-mail: smbala99@hotmail.com Vol. 15, No. 3,2002 Journal of Interventional Cardiology 209 zyxwvu zyxwv zyxwv BALANESCU, ET AL. This report describes a case of a coronary-to-pulmonary artery fistula in a patient with early angina after Q wave myocardial infarction and a single atherosclerotic coronary lesion that were both successfully treated by a single expanded polytetrafluoroethylene (ePTFE) covered stent graft. Case Report A 47-year-old male Caucasian was referred for coronary angiography in the setting of early postinfarction angina. He suffered an anterior myocardial infarction 2 weeks before admission. The patient had a zyx zyx zy 2-year history of exercise angina prior to his heart attack and developed angina and ST-segment depression in the precordial leads in stage 4 of a Bruce protocol exercise test 6 months before infarction. He was a moderate smoker (10 cigarettes per day). Anteroseptal acute myocardial infarction was diagnosed in a hospital without catheter laboratory facilities 5 hours after chest pain onset. Standard 12-lead ECG showed 1.5mm ST-segment elevation in V1-V3. He received thrombolytic therapy recombinant tissue plasminagen activate (@A) and showed proof of reperfusion with an early peak serum level of creative kinasel (CK) and CK myocardial bound (MB) at 10 hours. At 24 hours, a QS complex in VI-V3 was noted with all isoelectric ... . . Figure 1. Left anterior oblique 90-degree caudal projection (A) and right anterior oblique 30-degree caudal projection (B) of the left anterior descending coronary artery are shown at basal angiography. A stenosis in the proximal segment of the vessel is evident (white large triangle). The fistula origin (arrow) with small branches emerging from it (small triangles) is shown. The coronary-topulmonary shunt jet is clearly seen in Panel B (small triangle). Panel C shows intracoronary ultrasound (ICUS)examination at the segment of maximal stenosis (for ICUS measurements see the text). 210 Journal of Interventional Cardiology Vol. 15, No. 3,2002 STENT-GRAFT FOR CORONARY FISTULA AND STENOSIS artery was engaged with an 8F-JL4 guiding catheter ST segment in the same precordial leads. Five days af(Cordis, Miami, FL, USA). Then, a 3F-electronic ter thrombolysis, he developed rest angina with tranmonorail ICUS probe (Invision, Endosonics, Rancho sient ST-segment depression in the same precordial Cordova, CA, USA) was placed distally to the LAD leads. Transthoracic echocardiography showed no stenosis over a standard floppy 0.014” Balance Middle pericardial effusion, anteroapical and septal hypokineWeight (ACS Hi-Torque) guidewire and a videoloop sia, and a global ejection fraction of 0.48. was recorded with an automatic 0.5 m d s e c pullback He was admitted 14 days after the index coronary device. The reference maximum lumen diameter of the event for coronary angiography because of early proximal LAD was 4.5 mm and the vessel lumen area postinfarction angina with rest ST-segment depreswas 17.1 mm’, respectively. Minimum vessel diamesion. ter of the plaque-containing segment was 3.5 mm and Coronary angiography showed single vessel disease the minimum lumen area was 10.2 mm2.This resulted of the left anterior descending artery (LAD) (Fig. 1A in a calculated lumen stenosis of 40%. A single origin and B). A focal, short, concentric, and noncalcified leof the fistula was identified by ICUS in the LAD wall sion resulting in a luminal stenosis of 40% was identiwith an ostial diameter 1.9 mm. fied in the proximal segment of the vessel. The lesion After ICUS examination, an expanded polytetrafluwas assessed by quantitative coronary angiography oroethylene (ePTFE)-covered stent (Jostent, Jomed and intracoronary ultrasound examination (ICUS) International AB,) 2.5-5 X 19 mm was handcrimped (Fig. 1C). over a 4.0 X 20 mm World Pass Plus balloon catheter In addition, a coronary-to-pulmonary artery fistula (Cordis). The stent graft was positioned in the proxiwas present in the same segment of the LAD and conmal LAD to cover the origin of the fistula and the nected it to the main pulmonary artery (Fig. 1A and B). atherosclerotic lesion. The stent was deployed at high The fistula emerged distally to the coronary artery leinflation pressures (16 atm). Final contrast injections sion. No septal or diagonal branch was noted to origidemonstrated complete exclusion of the fistula and no nate in the same vessel segment. The circumflex and residual LAD stenosis (Fig. 2A and B). Repeated right coronary arteries were normal. Left ventricular ICUS examination demonstrated good apposition of angiography showed mild anteroapical hypokinesia the stent struts against the vessel wall and complete exand mildly depressed systolic function (global ejection clusion of the fistula. fraction 0.50). Right and left heart catheterization exThe patient was discharged 48 hours after percutacluded other left-to-right shunts and confirmed normal neous coronary angioplasty (PTCA). At 4 months, the pulmonary pressures and resistance. The calculated patient was still asymptomatic and a maximal treadpulmonary to systemic flow ratio was 1 3 1 . mill exercise test was negative. Therapeutic Procedure. The authors decided to treat the LAD atherosclerotic lesion and fistula in the setting of early postinfarction angina with documented Discussion rest ECG changes. There is a recognized relation between myocardial ischemia and infarction in the presRelation Between Coronary Fistulas and Myence of coronary fistulas even in the lack of significant ocardial Ischemia. Several authors reported that coroatherosclerotic coronary artery stenosis. nary artery fistulas are frequently associated with mySurgical closure was not considered because of ocardial i~chemia.’~.’~ Increased blood flow over the moderate shunt severity and the presence of mild proxsystemic-to-pulmonary fistula may lower distal intraimal single vessel disease that did not justify the risks coronary diastolic pressure and produce ischemia by a of surgery. However, percutaneous procedures like seSeveral case relective alcohol injection26 or coil e m b o l i ~ a t i o n ’ ~ ~ ’ ~“coronary steal ports of myocardial infarction in the presence of a would have allowed treatment of the fistula alone. coronary artery fistula without coronary atheroscleroTherefore, the authors planned to use a covered stent sis have been published. 13*25 graft as the best option to treat the LAD fistula and The concomitant presence of a coronary fistula and stenosis. coronary artery disease have also been de~cribed.’~ In Prior to coronary intervention, heparin was given these cases, the severity of myocardial ischemia in(100 U k g of body weight) to obtain an activated clotcreases when the “coronary steal phenomenon” is asting time (ACT) > 300 seconds. The left coronary zyxwvutsrq zyxwvut zyxwv zyxwvut Vol. 15, No. 3,2002 Journal of Interventional Cardiology 21 1 zyxwvu zyxwvu BALANESCU, ET AL. dure. Coronary angiography was instead performed 2 weeks after systemic thrombolysis for acute Q wave myocardial infarction and coronary thrombus could no more be identified. Procedures to Percutaneously Close Coronary Fistulas. Soon after coronary fistulas were recognized, surgical closure was the most widely technique used.I5 Some investigators advocated surgery even in asymptomatic patients to reduce the risk of long-term complications.16*29*30However, in surgical series there is an inherent risk of perioperative mortality of 2 4 % and myocardial infarction of 3.6%.15 Recently, some catheter-based techniques have been introduced as alternative strategies to reduce the risks of cardiac surgery, hospital stay, and intervention related These included detachable balloons, platinum coils or different chemicals, like pure alcohol. 17-2Q*26 All these techniques have been designed for fistulas unaccompanied by coronary disease. In the present case, the use of a stent graft to close the fistula was suggested by the concomitant presence of an atherosclerotic lesion in the same coronary segment. Coronary Stent Grafts. Serious complications of PTCA and stenting, like coronary rupture or late aneurysm formation have been successfully treated by stent graft implantation.22The rationale for using this type of stent for coronary fistula closure is derived from the quality of the stent graft to form an artificial vessel wall that allows exclusion of aneurysms or sealing vessel ~ e r f o r a t i o n . ~ ~ . ~ ~ Recently, a new type of ePTFE-covered stent grafts (Jostent) has become available. The Jostent coronary stent graft consists of two stainless steel slotted tube stents that fix in between a layer of ePTFE.21*22 Autologous vein-covered stents have also been used to treat coronary artery disease.32However, surgical preparation of the vein to cover the bare stent can be difficult and time consuming. One important limitation of stent graft implantation in the coronary arteries is the stent dependent occlusion of side branches originating from the same target segment. This may represent a serious problem in the LAD where important septal branches or diagonal vessels may originate.22In the case of a coronary fistula, this major disadvantage of side branch occlusion becomes a therapeutic target, as the exclusion of the fistula may thus be achieved. In the present case, the anatomic presentation was favorable for stent graft implantation since no other side branch originated in the stented segment. zy zyxwvutsrqp Figure 2. Control angiography after expanded polytetrafluoroethylene (ePTFE) covered stent deployment in the left anterior oblique 90-degree caudal projection (A). Complete disappearanceof both stenosis and fistula origin have been obtained. At the intracoronaty ultrasound examination (B), the stent struts are well apposed against the vessel wall, and a large lumen with smooth contour is evident. sociated with atherosclerotic involvement of the same coronary a ~ - t e r y . ~ * * ~ ~ As reported in previous angiographic studies, in the patient in this case report myocardial infarction could be probably due to acute coronary thrombosis on an uncritical atherosclerotic plaque that appeared nonulcerated and thrombus-free at angiography and ICUS e ~ a m i n a t i o n . ' ~The * ~ *mechanism of myocardial ischemia and infarction in this case could have been elucidated if diagnostic coronary angiography and an ICUS procedure would have been performed early during an emergency invasive revascularization proce212 Journal of Interventional Cardiology Vol. 15, No. 3,2002 STENT-GRAFT FOR CORONARY FISTULA AND STENOSIS zyxwv zyxwv zyxwvuts zyxwvu Another significant problem with the use of covered stents is the extended surface of foreign material deployed to the vessel-blood interface (stent and synthetic membrane). This may predispose to acute closure and delayed endothelization of the stent that may lengthen the need of ticlopidine administration.22However, the authors have recently showed that acute and subacute thrombosis and restenosis have a similar rate to that of bare stent implantationin a swine experimentalmodel.33 14. 15. 16. 17. 18. Conclusion 19. 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