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Closure of Coronary Artery Fistula with a Graft Stent and Correction of Stenosed Left Anterior Descending Artery in the Same Procedure

- Operator: Seung-Jung Park, MD, PhD, FACC

A 50-year-old woman was admitted with effort-related chest pain for several months. The coronary risk factor was diabetes mellitus. The EKG showed precordial T-wave inversion and thallium SPECT revealed moderately decreased perfusion defect in the anterior wall. Coronary angiogram showed a diffuse long lesion of the proximal and middle part of the left anterior descending artery (LAD) and a coronary artery fistula originating from a tortuous septal branch of proximal LAD, finally draining to the main pulmonary artery (Figure 1, Figure 2, Figure 3).

The procedure was performed with IVUS guidance. We deployed a bare metal stent (Tsunami 3.0 x 20 mm, Terumo Corp) for the middle LAD lesion (Figure 4, Figure 5). Then a 3.0 x 16 mm PTFE covered stent (JOSTENT? JOMED) was deployed in the proximal LAD to seal the ostium of the septal branch supplying the fistula (Figure 6, Figure 7). Adjunctive high pressure balloon dilatation was subsequently performed to maximize the lumen diameter. No residual fistula and shunt flow was found on the final angiographic image (Figure 8, Figure 9, Figure 10). Post-stent IVUS study showed a large CSA proximal to the middle portion of the LAD (Figure 11; A-fisutula opeing at 3 o'clock, B-after covered stent implantation). The covered stent was well positioned and fully covered the septal branch providing the fistula. The antiplatelet regimens included aspirin, clopidogrel for 3 months

i would have embolized the fistula and not exposed the patient to restenosis in the prox lad using the jomed graft,unless the size of the fistula prohibited safe coil embolization. assuming the guide shots are with a 6f system the fistula does not appear to be larger than 3mm. this is a more elegant solution that avoids trauma to the lad .another thought: does the fistula need embolization. the ant wall ischemia may be due to the stented lad atherosclerosis and nothing to do with the fistula. a shunt study should be performed prior to deciding to close the fistula by whatever method. great case for discusssion!.
Seung-Jung Park2004-06-29
I fully agree with your comments. We need more objective evidence of ischemia realted with the fistula. In any case, for particular this case, I don't have much concerns about the restenosis of normal pLAD using Jomed Graft stent. Thanks for discussion.
Hweung-Kon Hwang2004-07-02
I fully agree with the Dr Sryvasta's opinion. Unless 1) the multiple channels in both side of the coronary and pulmonary artery,like a-v malformation is the case ,or 2) microcather with or without coil is hard to reach the optimal site for coil deployment, or 3) the length of the fistular vessel for coil deployment site is too short with fear of extruding the proximal part of the coil in the feeding coronary, or 4) the fiatular vessel is too large to coil embolization, I think coil embolzation is better treatment. Of course, I will check the Qp/Qs and pulmonary pressure by right catheterization.
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