Retrospective review of M3C-Necker experience with transcatheter management of coronary artery fistulas

Abstract

Introduction

Coronary artery fistulas (CAFs) are rare coronary anomalies and transcatheter closure remains debatable.

Objective

To evaluate our experience with transcatheter management of CAFs.

Methods

Retrospective clinical data review of all children in whom echocardiographically suspected CAFs were confirmed during cardiac catheterization from 2000 to 2022.

Results/Expected results

In total, 92 CAFs were identified in 76 patients (44% males) with a median age of 3.8 years (IQR, 0.8–7). 25 (32.9%) patients had concomitant congenital anomalies and 9 (11.8%) had coronary artery anomalies. 39/51 (76.5%) patients with isolated CAFs were asymptomatic at diagnosis. 27 (35.5%) patients had pre-procedural CT angiography. CAFs mainly originated from the left main coronary artery (42.4%) and right coronary artery (38.1%). Drainage sites were mainly the right cavities (80.4%). 23/76 (30.3%) patients with 35/92 (38%) small CAFs had no intervention with a benign clinical long-term follow-up. 8/76 (10.5%) patients with 9/92 (9.8%) CAFs not amenable to percutaneous closure were directly sent for surgery. 45/76 (59.2%) patients had percutaneous closure of 48/92 (52.2%) CAFs using microcoils (31.3%), device occluders (58.3%), or both (10.4%). Occlusion material was exchanged before release in 4 (8.9%) patients. Devices were deployed transvenously using a track wire loop in 19/48 (39.6%) CAFs. Closure approach was modified per-operatively in 4 (8.9%) patients. Percutaneous closure was unsuccessful in 3 (6.7%) patients of which 2 had surgical ligation. Twelve complications occurred including 7 transient ST–T wave changes, 2 asymptomatic coronary pseudo-stenosis, one coronary dissection, and one pulmonary edema. Repeat closure was needed in 3 (6.7%) patients for residual leak and was unsuccessful in 2 of them. One patient had trivial CAF recanalization with an asymptomatic 12-year follow-up.

Conclusion/Perspectives

Transcatheter closure of CAFs is feasible and effective in carefully selected patients. Complications are frequent but not permanent. Surgery is a valuable upfront option in large and technically complex CAFs or a bailout of failed percutaneous attempts.