Nitin Sood, Christoph Mailaender
HerzZentrum Saar, SHG Kliniken Voelklingen, Germany
A 67-year-old man (170cm, 109kg; BMI: 37,7) who experienced intermittent chest pain (CCS Class III), dyspnea (NHYA Class III) and dysphony for approximately two years.
Previous transradial diagnostic angiography via the right radial approach revealed a chronic total occlusion (CTO) of the second diagonal branch which could be successfully recanalized using a Medtronic Launcher 7Fr EBU 4.0 via a Terumo 7Fr Glidesheath Slender. A lose large fistula originating from the left anterior descending coronary artery (LAD) to the pulmonary artery with its orifice in the mid segment of the LAD, originating just after the third diagonal branch (Figure 1a and 1b), was diagnosed; this was staged for a second procedure.
Figure 1 a): AV Fistula, originating from mid LAD to pulmonary artery in LAO 6 (caudal 29) view
Figure 1 b): AV Fistula, originating from mid LAD to pulmonary artery in LAO 48 (caudal 15) view
After re-accessing the right radial artery utilizing a Terumo 7Fr Glidesheath Slender, a 7Fr guiding catheter (Medtronic Launcher 7Fr EBU 4,0) could be negotiated through the tortuous anonyma artery into the LCA.
A workhorse coronary guidewire was placed distally into the fistula and a selective injection via a microcatheter (MC) revealed the diameter of the fistula. We placed four 18S Tornado embolization Microcoils via 2.8Fr Cantata Microcatheter (Cook Medical) using a 0.018 inch coil pusher (Cook Medical).
The final angiogram confirmed complete closure of the AV fistula with no flow of contrast dye towards the pulmonary artery (Figure 2a and 2b).
Figure 2 a: Embolisation microcoils in situ with complete closure of AV fistula in LAO 6 (caudal 29) view
Figure 2 b: Embolisation microcoils in situ with complete closure of AV fistula in LAO 48 (caudal 15) view
The transradial approach is feasible in the closure of an AV fistula using a large bore guiding catheter utilizing a 7Fr Terumo Glidesheath Slender.
The patient could do heavy exercise without symptoms at follow up within 12 weeks.