MANAGEMENT OF CORONARY ARTERIOVENOUS FISTULA BY DEVICE

Abstract

Coronary arteriovenous fistulas can be managed surgically or lately by transcatheter occlusion using various devices. We report a child where it was closed percutaneously and review the literature. An 11 -year old boy had clinical and echocardiographic features of a fistulous communication between the aorta and the right atrium. Selective angiography showed a large fistula between the left coronary artery and the right atrium. Access to the fistula was obtained via the right femoral artery and the right internal jugular vein. An extrastiff 0.035" exchange guidewire was passed from the femoral artery through the fistula into the right atrium and snared from the jugular venous approach. A 10-8 Amplatzer Duct Occluder was advanced from the internal jugular vein through an 8 Fr Mullins sheath placed over the guidewire antegradely into the fistula. The fistula was occluded successfully with no evidence of ischemia on ECG or on serial measurement of cardiac enzymes. Repeat angiography six weeks later showed the occluder in position with complete occlusion of the fistula. The right coronary artery was the dominant vessel while the left anterior descending coronary artery and the obtuse marginal artery arising from the fistula had increased in size. The cardiac size regressed with no left ventricular akinesia or dysfunction on echocardiography. Occlusion of coronary arteriovenous fistula with an Amplatzer Duct Occluder is a safe and effective alternative to surgery in selected patients.