Transcatheter closure of coronary arterial fistulas using the new Amplatzer vascular plug

Abstract

We report our initial experience in using the Amplatzer vascular plug for closure of coronary arterial fistulas. The self-expanding, cylindrical, device is made from Nitinol wire mesh, and is available from 4 to 16 millimetres in diameter. We have now used the device to close fistulas in 3 patients, aged from 3 to 14 years, who presented with ratios of pulmonary-to-systemic flow from 1.5 to 3. In 2 patients, fistulas arising from the proximal right and left coronary arteries, with maximal diameters of 9 and 10 millimetres, respectively, had their narrowest diameter, of 6 millimetres, proximal to the entrance into the right atrium via a saccular aneurysm. The third fistula, with a maximal diameter of 16 millimetres, and with its origin from the circumflex coronary artery, entered the right atrium with nearly unrestricted flow, its narrowest diameter being 8 millimetres. For interventional closure, we chose plugs twice the diameter of the narrowest segment of the fistula, thus using 2 devices of 12 millimetres and one of 16 millimetres diameter. An arteriovenous loop was established through the fistula by snaring an exchange guide wire. Using a 7 or 8 French guide catheter inserted through the femoral vein, all plugs were placed at the narrowest segment of the fistula, leading to immediate complete closure of 2 fistulas. The third patient, with a fistula of the circumflex coronary artery, who received the largest plug initially had residual flow, but the fistula was found to be completely occluded at 12 months follow-up examination. We have demonstrated, therefore, safe and effective usage of the new vascular plug for transcatheter closure of moderate- to large-sized coronary arterial fistulas. The plug offers an alternative to cardiac surgery, or occlusion using coils.