Mazeni Alwi Institut Jantung Negara
(National Heart Institute) Kuala Lumpur
Malaysia
Coronary AV fistula – When to close
by catheter or surgical approach
5th Asia Pacific Congenital & Structural Heart Intervention Symposium 2014 (APCASH) 10 – 12 October 2014, Hong Kong Convention & Exhibition Centre
Justification for closure…
Lithbertson et al. Circulation
174 cases Operative mortality 1% in patients <20 years, 7% in those >20 years
(operative complications 7% vs 23%)
Younger patients were less likely to be symptomatic or have
complications related to CAF (19%), 63% in those >20 years Late complications
Cardiac failure Angina from coronary steal Rupture and tamponade Thrombosis and infarction Arrhythmia
Interventional era
Rare, very varied morphology
Majority of CAF are amenable to transcatheter closure – coils, Amplatzer line of device (vascular plug, ADO I, ADO 2, mVSD device …)
Frequently shown at live case demonstrations Good learning points for assessment of
morphology and techniques of closure
Reasonable body of literature on techniques and early results of transcatheter closure ? Antiplatelet/anticoagulation management ? Medium and long term outcome
When to close CAF …
Transcatheter closure – when is the optimum time?
When is surgical closure preferable?
When is non-closure (no treatment) preferable?
Coronary artery fistula
Usually in younger age group
Often single, not tortuous
Shunt limited by narrowed opening to sink – no symptoms
Heart failure – uncommon (no distal constriction)
Continuous murmur
Usually in older children / adults Tortuous, often multiple No obvious constriction Soft murmurs, silent + Chest pain
Large fistula (>2 x native vessel diameter)
Small fistula (<1.5 x native vessels diameter)
Group A (n=18) Large CAF (>2 x native vessel)
Group B (n=8) Small CAF (<1.5 x native vessel)
Median age (yrs) 8 (1-51) 7 (1-65)
Median weight* (kg) 20 (7.5-60) 14 (4-75)
M:F 5:13 4:4
Symptoms: a)Congestive cardiac failure b)Myocardial ischemia
1 (5.5%) 0 (0%)
1 (12.5%) 2 (25%)
Diameter (mm) 9.8 (5.4-19.9) 3.3 (2.7-4.0)
No. of feeders 1 2 3 4
17 (94%) 1 (6%) 0 0
1 (12%) 5 (64%) 1 (12%) 1 (12%)
Presence of discreet stenosis* 18 (100%) 2 (25%)
Tortuosity** (2 or more acute bends)
0 8 (100%)
Institut Jantung Negara (National Heart Institute), Kuala Lumpur, Malaysia
1994 – 1997 Table 1 : Patient Characteristics
Transcatheter closure … when ?
Coils – delivered via end hole diagnostic catheters 5-6F (flexible enough) but multiple coils often required, ↑ risk of coil migration
ADO, ADO II, mVSD device, vascular plugs … Highly effective, small risk of migration but requires delivery
sheath (+ dilator – very stiff) + need to create A-V loop Catheters, sheath, wires inside coronary arteries … preference
for closure >5 years of age unless the patient is symptomatic or CAF conduit is aneurysmal
Viable myocardial branches in proximity site of device placement – allows more room for manoeuvre in bigger patients
Large coronary artery fistula
7 years, M Circumflex to RV apex, closure with Gianturco coils
Improvement of flow into normal branches post occlusion of fistula
Gabriel1&2
5 years, M Circumflex to RA AV loop for balloon occlusion test and angiogram, ADO delivery transvenous
Ayuni1&4
6 years, F RCA to RA AV loop for multi-track catheter and delivery sheath Closure with mVSD device
Kwoo1-4
5 years, F LCA to LV
Kwoo5&6
5 years, F LCA to LV Closure with ADO II
Transcatheter closure of small CAFs
Very tortuous, may be multiple Often no obvious discreet constriction Presentation at older age : Soft murmur, occasionally chest pain (coronary
steal)
9 years, F, small multiple CAF, LCA to RV 45 years, M, Single small CAF, LCA to MPA, steal symptom
Should be done at older age – manoevering of wires and catheters in small tortuous vessels - ↑↑ risk in small children
Small CAFs
GDC platinum microcoils - released by passage of electrical current (electrolysis)
Delivered via infusion catheter (Rapid transit by Cook with 0.021” lumen, Tracker by Target Therapeutics 0.018” lumen) coaxially with diagnostic coronary catheters
Electrical power supply
Diagnostic coronary catheter
Infusion catheter for coil delivery
Coil pusher
Coil pusher wire
Electrolytic detachment of coil
18 years, M “Small CAF”, LAD to RV Platinum microcoils delivered via infusion catheter within JL diagnostic catheter
Small CAFs
Small size, arising from mildly dilated RCA/LCA, close to many normal branches, coming off at difficult angles
Needs precise coil placement deep in target vessel to avoid ischaemia/infarction
Accessible by small 3F infusion catheter over coronary guidewire to navigate multiple acute bends
Use of controlled release platinum microcoils
ADULT CARDIOLOGY SUPPORT ESSENTIAL (choice of wires, catheter manipulation)
9 years, F, small, multiple CAF LCA to RV
Closure of small, tortuous CAF
coils
Use of platinum microcoils Better flow into feeder artery after elimination of ‘steal’
45 years, M, Single, small fistula, LCA to MPA
When is surgical closure preferable
5 year, F, asymptomatic, continuous murmur, RCA fistula to RV, Normal branches arising off the fistula near exit point
Presence of myocardial branches near intended site of device placement (site of constriction)
Large CAF with no constriction – large L R shunt, cardiac failure (usually neonatal/early infancy presentation)
No constriction to hold device in place, ↑↑ risk of migration Stiff sheath + dilator in coronary artery of small infants !
Conclusions
Largely amenable to transcatheter closure – coils, Amplatzer devices, microcoils for small tortuous fistula
Timing of intervention: >5 years if asymptomatic Risk of maneuvering of catheters, wires and sheaths in coronary artery of
young children Much old age for tortuous, small fistula
Cases for surgery – myocardial branches arising at/near site of intended device placement, large CAF with no constriction
TIMING : >5 years if no symptoms
Increasing reports of coronary events post closure ? Role of non-intervention for CAF high risk of thrombosis ? More aggressive anticoagulation regime post closure
Thank you
Ayuni2&3
Exit point near right A-V grove Use of torque-vue sheath for delivery of ADO Distal branches not occluded by ADO