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Transcatheter Coil Embolization and Cypher Stent Implantation for the Coronary Arteriovenous Fistula and LAD Stenosis

- Operator: Myeong-Ki Hong, MD, and Min-Kyu Kim, MD
Case presentation
The patient was a 62 year-old male. He presented with effort chest pain. His coronary risk factor was smoking. His baseline ECG showed T wave inversion in V1-V4.
Baseline coronary angiography
Right coronary angiogram showed a large AV fistula originating from the ostium of the right coronary artery (RCA) (Figure 1). Left coronary angiogram (Figure 2, Figure 3) showed a coronary AV fistula having multiple feeding vessels and originating from a septal branch of the middle left anterior descending artery (LAD), and a diffuse narrowing at the middle LAD.
Procedures
For treatment of RCA fistula, a 7 Fr LCB guiding catheter was engaged into the right AV fistular ostium at the RCA ostium. A 0.014 inch Choice PT wire was successfully introduced into the fistula under the support of Renegade microcatheter (Boston Scientific). After then, we removed a Choice PT wire. Next, we connected delivery catheter including the Tonade embolization microcoil with Renagade microcatheter. Then, the Tornade embolization microcoil was advanced to the distal portion of the fistula with 0.014 inch Transend guidewire. three 4-2mm Tornado embolization microcoils and one 6-2mm Tornado embolization microcoil were deployed into the middle segment of the fistula (Figure 4, Figure 5).
For treatment of LAD fistula and stenosis, a 7 Fr XB 3.5 guiding catheter was engaged into the left main ostium. Using same technique, we deployed four 3-2mm Tornado embolization microcoils at a larger feeding vessel of the left AV fistula (Figure 6, Figure 7). After coil embolization, a 0.014 inch Choice PT wire was introduced into the LAD for the treatment of LAD lesion. After predilatation with a Stormer balloon (2.5x20mm at 8 atm, Medtronic), a Cypher stent (3.5x18mm at 20 atm) was deployed (Figure 8). Final left coronary angiogram showed no residual narrowing at the middle LAD and marked reduction of blood flow into the fistula (Figure 9). A day after index procedure, a follow-up angiogram of the fistula was obtained. This revealed a successful obliteration of right AV fistula (Figure 10), and an incomplete occlusion of left AV fistula due to other small feeding vessels (Figure 11, Figure 12). However, further treatment was not done because marked reduction of shunt flow through the fistula was obtained.
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