Percutaneous Coil Embolization for Symptomatic Coronary Fistula

Abstract

Pre-operative optimization of cardiovascular conditions in patients awaiting renal transplantation significantly improves post-transplantation cardiac complications. We describe a case of symptomatic coronary fistula treated with percutaneous coil embolization in a young adult awaiting renal transplantation. (Level of Difficulty: Advanced.)

Graphical abstract

A 28-year-old male presented for a pre-operative assessment in preparation for renal transplantation (RT). He reported intermittent exertional chest pain for the last 6 months. Vital signs were within normal limits and physical examination findings were remarkable only for an arteriovenous dialysis fistula. He had a history of medullary cystic kidney disease type 1 complicated by end-stage renal disease requiring hemodialysis for the previous 6 years. A regadenoson nuclear stress test result revealed a moderate zone of inferior wall myocardial ischemia. Coronary angiography revealed a right-dominant system with a large coronary artery fistula (CAF) originating from the conus branch of the right coronary artery with a superior take-off to the pulmonary artery (Figure 1A, Video 1). Angiography did not demonstrate coronary artery disease. It was decided to pursue percutaneous coil embolization of the CAF. After multiple Azur Cx peripheral coils (Terumo, Somerset, New Jersey) were successfully deployed, the CAF was sealed, and the patient was discharged home with a prescription of aspirin (81 mg) for 30 days (Figure 1B, Video 2). He underwent successful nonliving-donor renal transplantation 2 months after, with no perioperative cardiovascular complications at the 2-month follow-up.

Figure 1.

Coronary Angiogram, LAO View

(A) Coronary angiogram, LAO view. Coronary artery fistula (arrow) originating from the conus branch of the RCA with a superior takeoff to the PA. (B) Coronary angiogram, LAO view. Coronary artery fistula originating from the conus branch of the RCA (star) with no flow into the PA after 6 Azur Cx coils were deployed in its distal end (arrow). LAO = left anterior oblique; PA = pulmonary artery; RCA = right coronary artery.

CAF is defined as a communication between the coronary artery and the cardiac chamber or a great vessel (1). The incidence of congenital CAF is 0.1% to 0.2% in patients undergoing coronary angiography (1). Adult patients with CAF are mostly asymptomatic, but cardiac symptoms (i.e., dyspnea, chest pain) and complications such as myocardial infarction, sudden death, and heart failure have been reported (2). In patients with CAF, a coronary artery “steal” phenomenon results in coronary blood, preferentially passing through the fistula instead of the microvascular coronaries arteries (2). The present patient had an indication for closure of his CAF because he was symptomatic. Percutaneous transcatheter closure of congenital CAF has been well described for the treatment of CAF (2). Another option would have been covered stent implantation on the ostial right coronary artery. However, given the risk of stent restenosis and thrombosis in a young patient, coil embolization was chosen as the best option.

Recently, the ISCHEMIA-CKD (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches–Chronic Kidney Disease) trial did not show benefit of survival of initial coronary revascularization relative to that of conservative medical management in patients with chronic coronary syndrome, advanced chronic kidney disease, and moderate or severe ischemia on stress testing results (3). The impact of pre-operative treatment in symptomatic CAF in patients awaiting organ transplantation is unknown. The Organ Procurement and Transplant Network reported nearly 93,000 candidates on the waiting list for RT in 2018, and only approximately 21,000 received renal transplantations. Unfortunately, some candidates may be turned down for transplantation based on the results of cardiac screening procedures or may be removed from a deceased donor transplantation waitlist after the accumulation of cardiac morbidity over time. Given the disparity between end-stage renal disease patients on the waitlist and the RT recipients, delaying renal transplantation due to recognized cardiac ischemia may have deteriorating effects on survival. This gives the new promising role to the pre-RT cardiac revascularization as it may facilitate renal surgery that improves patient survival.

Author Disclosures

This publication was supported by a generous grant from the Mary K. Oxley Foundation. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.