Percutaneous management of coronary artery fistula in acute coronary syndrome using a covered stent crush technique: a case report

Abstract

Background: Coronary artery fistulas (CAFs) are abnormal vascular connections that allow blood to drain from another vessel or heart chamber, potentially leading to angina and heart failure. While often discovered incidentally, medium-sized and large CAFs necessitate closure to prevent hemodynamic complications. This case report describes a novel application of the bifurcation 'crush' technique in the treatment of a coronary artery fistula.

Case presentation: A 72-year-old woman was admitted to the emergency department with chest pain and was diagnosed with non-ST elevation myocardial infarction (MI). Coronary angiography revealed severe coronary stenosis and a large fistula. The large fistula was successfully treated by crushing a covered stent. This method treats the coronary fistula as a side branch while identifying the originating vessel as the main vessel. A covered stent is inserted into the coronary fistula, extending to the main vessel. The protruding segment is subsequently crushed via an open-cell drug-eluting stent parked within the main vessel.

Conclusion: This case highlights a different technique for managing large coronary fistulas among nonsurgical options. The use of drug-eluting stents to crush a covered stent effectively manages coronary fistulas, offering an alternative to traditional surgical or percutaneous methods. However, the absence of follow-up imaging limits the ability to confirm long-term stent patency or detect restenosis.

Keywords: Acute coronary syndrome; Bifurcation technique; Coronary artery fistula; Covered stent; Non-surgical closure; Structural intervention.

Fig. 1

A 12-lead electrocardiogram (ECG) was obtained at the time of the patient’s initial presentation at the hospital

Fig. 2

Angiographic visualization of the coronary fistula and aneurysmal segment. A Coronary angiography revealed a fistula that originated from the left anterior descending artery (LAD) and drained into the main pulmonary artery (MPA). B Asterisks indicate a significantly dilated aneurysmal segment, morphologically resembling a magician’s hat. (LAD= left anterior descending artery; MPA = main pulmonary artery)

Fig. 3

Stepwise illustration of the procedure. A A 4.0 mm × 20 mm PK Papyrus covered stent (CS) was advanced into the coronary fistula, whereas a 4.0 mm × 22 mm drug-eluting stent (DES, Resolute Integrity) was positioned in the left anterior descending artery (LAD). B The CS was deployed with a 4–5 mm protrusion into the LAD, and the guidewire inside the fistula was withdrawn. C The DES was implanted in the LAD to crush the protruding portion of the CS. D The crushed segment was further optimized with post-dilatation using a 4.5 mm × 12 mm non-compliant (NC) balloon. E Final angiography confirmed complete occlusion of the fistula and successful sealing of the CS ostium. (CS = covered stent; DES = drug-eluting stent; LAD = left anterior descending artery; NC = noncompliant balloon)

Fig. 4

Angiographic confirmation of complete occlusion of fistula flow. A RAO cranial plane; B LAO cranial plane. (RAO = right anterior oblique, LAO = left anterior oblique)