Device closure of fistula from left lower pulmonary artery to left atrium using a vascular plug: A case report

Abstract

Background: Pulmonary artery-to-left atrial fistula is a variant of pulmonary arteriovenous fistula and is a developmental anomaly. Delayed presentation, cyanosis and effort intolerance are some of the important features. The diagnosis is confirmed by computed tomography or pulmonary artery angiography. Catheter-based closure is preferred to surgery.

Case summary: Left pulmonary artery-to-left atrial fistula is rare. A 40-year-old male presented with effort intolerance, central cyanosis, and recurrent seizures. He had a large and highly tortuous left pulmonary artery-to-left atrial fistula associated with a large aneurysmal sac in the course. Catheter-based closure was performed using a vascular plug.

Conclusion: Left pulmonary artery-to-left atrial fistula is relatively uncommon compared to right pulmonary artery-to-left atrial fistula. Percutaneous closure by either a transeptal technique or guide wire insertion into the pulmonary vein through the pulmonary artery is preferred. The need for an arteriovenous loop depends on the tortuosity of the course of the fistula and the size of the device to be implanted because a larger device needs a larger sheath, necessitating firm guide wire support to facilitate negotiation of the stiff combination of the delivery sheath and dilator.

Keywords: Case report; Catheter-based; Fistula; Hemangioma; Left atrium; Pulmonary artery; Vascular plug.

Figure 1

Three-dimensional computed tomography volume rendering and pulmonary artery angiogram. A: Contrast-enhanced computed tomography with three-dimensional reconstruction showing the left lower pulmonary artery-to-left atrial fistula with a highly tortuous course associated with an aneurysmal sac. Yellow arrow: left lower segmental artery; red arrow: aneurysmal sac; green arrow: last part of fistula connecting the left atrium; B: Anterior-posterior projection of pulmonary artery angiography using a 6-Fr pigtail catheter showing a highly tortuous large left pulmonary artery-to-left atrial fistula associated with a 6-cm aneurysmal sac. The right ventricular oxygen saturation was 79%, and the left ventricular saturation was 92% in room air without anesthesia.

Figure 2

Lateral pulmonary angiography and the course of the guidewire. A: Lateral pulmonary artery angiography using a 6-Fr pigtail catheter showing a large left pulmonary artery-to-left atrial fistula associated with a large aneurysmal sac; B: A Terumo wire (0.35 cm × 260 cm) and 5-Fr multipurpose catheter helped to negotiate the highly tortuous course of the fistula to reach beyond the targeted landing zone and the site of guide wire placement in the upper right pulmonary vein via the aneurysmal sac for adequate support. Red arrow: 8-Fr sheath; yellow arrow: 5-Fr multipurpose catheter through the delivery sheath; blue arrow: guidewire in the aneurysmal sac; green arrow: upper right pulmonary vein.

Figure 3

Pulmonary artery angiography after device deployment. Pulmonary artery angiography in the frontal projection and in the lateral projection showing perfect device positioning, no residual shunting and uncompromised blood flow in the left lower segmental artery. A: Frontal projection; B: Lateral projection.