Transcatheter Coil Embolization of Single Coronary Artery Fistula Using the Occlusion Test

Abstract

The case of a patient in whom hemodynamic and electrocardiographic studies using the occlusion test for coronary artery fistulas (CAF) were safely performed prior to catheter embolization is reported. A 1-year-old girl had a separate right coronary artery arising from a left single coronary artery that formed a significant coronary artery fistula to the right ventricle. Coronary steal by the large coronary artery fistula narrowed the left coronary artery. The right coronary artery branches could not be clearly identified due to an overlap with the fistula. Due to the long porous CAF, embolic procedures could cause serious complications. We confirmed the safety by performing an occlusion test of the CAF's proximal blood vessels. Following total occlusion of the CAF for 10 minutes, pulmonary arterial pressure and aortic blood pressure were not significantly changed. No bradycardia, atrioventricular block, or ST changes were observed. Coil embolization treatment was performed safely. For patients with long distal CAF complicated with a single coronary artery, myocardial ischemia and conduction system disorders can be identified by performing the occlusion test before embolization.

Figure 1

(a) 320-row coronary CTA. The single coronary artery view shows the anterior course of the separate right coronary artery coming off the LAD. This is the anterior view. (b) Selective coronary angiography of the LMT shows the LAD and the LCX with weak contrast effects and a CAF with “multiple caliber change” of the RCA to the right ventricle (arrowhead). (c) Occlusion test on the proximal site of CAF using an occlusion balloon (arrowhead). (d) Engaged microcatheter in the distal RCA and embolization using a detachable coil. (e) One year after coil embolization, selective LMT coronary angiography clearly distinguishes the contrast effect of the LAD and LCX, the sinus node branch branching from LCX (white arrow), and right ventricular branches from the proximal side of the RCA (asterisks). The proximal end of the coil-embolized CAF formed a thrombus and occluded (arrowhead). CAF: coronary artery fistula; CTA: computed tomography angiography; LAD: left anterior descending coronary artery; LCX: left circumflex coronary artery; LMT: left main coronary trunk artery; RCA: right coronary artery.