Dual Fistula Origınating from Left Anterior Descending Coronary Artery; Off-Pump Surgical Closure Technique

The incidence of multiple fistulas within all coronary arteriovenous fistulas varies between 10.7% and 16%. Double coronary-arteriovenous fistulas originating from a coronary artery are much less common. In this study, we present a double fistula originating from left anterior descending coronary artery and communicating with main pulmonary artery. A 72-year-old female patient was admitted to our clinic with complaints of chest pain and shortness of breath with progressive exertion. Coronary angiography revealed the presence of a double fistula originating from the LAD and a major pulmonary arterial drainage. Median sternotomy was performed. From the LAD proximal segment, two A-V fistulas with fragile tissue at the origin and connecting to the mid portion of the main pulmonary artery were identified. LAD exit site pulmonary arterial entry site identified. Exit locations and access sites were ligated with 5.0 prolene. No electrocardiographic and hemodynamic changes were detected. Several other vascular structures on the pulmonary artery were separately sutured. INTRODUCTION Coronary arterio-venous malformations are rare. They are mostly of congenital origin. They originate from embryogenic intertrabecular spaces and sinusoids between the heart chambers and the coronary circulatory system [1,2]. Acquired arterial-venous malformation is likely to occur. Although coronary artery fistulas are rare, they present a significant risk for myocardial ischemia, myocardial dysfunction, heart failure and infective endocarditis [3,4]. The incidence of multiple fistulas within all coronary arteriovenous fistulas varies between 10.7% and 16%. On the other hand, the incidence of arteriovenous fistula originating from two coronary arteries was 5% [5,6]. Double coronary-arteriovenous fistulas originating from a coronary artery are much less common. In this study, we present a double fistula originating from left anterior descending coronary artery (LAD) draining to main pulmonary artery. CASE PRESENTATION A 72-year-old female patient was admitted to our clinic with complaints of chest pain and shortness of breath with progressive exertion. On auscultation, a murmur of 2/6 intensity, which is continuous in the anterior mediastinum, was detected. No pathology was detected in the telegraphy and electrocardiogram. Findings of anterior ischemia were detected by the Treadmill effort test. Transthoracic echocardiography revealed the presence of a continuous flow on the main pulmonary artery. Coronary angiography revealed the presence of a double fistula originating from the LAD and a major pulmonary arterial drainage (Figure 1). Arterial blood gas analysis, there was a 10% saturation difference between the right ventricle and the pulmonary artery. Lady was admitted to our clinic for surgical reasons for the detection of pulmonary arterial high-flow double a-v fistulae. At another center, attempted coil embolisation failed (Figure 2). After necessary surgical preparations, the patient was operated. Figure 1 Coronary angiogram shown double LAD coronary artery fistula-main pulmonary artery. Central Yasa et al. (2017) Email: Ann Vasc Med Res 4(4): 1062 (2017) 2/3 Median sternotomy was performed. Pericardium was opened and suspended. From the LAD proximal segment, two curve A-V fistulas with fragile tissue at the origin and mid region of the main pulmonary artery were identified. LAD exit site pulmonary arterial entry site identified. Exit locations and access sites were ligation with 5.0 prolen. All A-V fistula strains were ligated with over and over suture technique. No electrocardiographic and hemodynamic changes were detected. Several vascular structures on the pulmonary artery were separately sutured (Figure 3). In the ABG analysis after the ligation procedure, there was no difference in oxygen saturation between the right ventricle and the pulmonary artery. On the fourth postoperative day the patient was discharged without any problems. There was no murmur on auscultation. Echocardiographic examination revealed that the current on the main pulmonary artery disappeared. At a follow up of 3 months, the patient is asymptomatic. DISCUSSION Coronary A-V fistulas are treated with various techniques. Patients with symptomatic and prominent A-V appendages may be surgically closed if they are not suitable for percutaneous closure. Ligation of the fistula under cardiopulmonary bypass is the simplest surgical procedure. Other surgical techniques; (46.1%), tangential arteriovenous (28.8%), distal ligation alone (11.5%), proximal and distal ligation (6.7%), ligation and coronary bypass graft (3.8%), aneurysmal coronary artery Arterial occlusion (2.9%) [7]. Cardiopulmonary bypass and cardioplegic arrest can be used in arteriovenous fistulas between the coronary-pulmonary arteries [8,9]. There are advantages and disadvantages of using cardiopulmonary bypass. The advantage is to make a small incision from the pulmonary artery and see the mouth of the fistula to place the suture. On the other hand, the oximetric study is possible only after weaning from CPB. Surgical intervention is also mandatory under cardio-pulmonary bypass in concomitant cardiac pathologies and complex fistulas. Off-pump can be safely used for simple fistulas without other cardiac anomalies. In this case, a successful surgical procedure was performed with off pump technique without CPB. Coronary artery fistulas are rare pathologies. Arteriovenous fistulas of coronary arteries are seen in 1-2%. The incidence of arteriovenous fistula according to outflow is 50-58% in the right coronary artery, 25% in the left anterior descending artery, 18.3% in the circumflex artery, 1.9% in the diagonal artery and 0.7% in the left main coronary artery [8,9]. The incidence of multiple fistulas within all coronary arteriovenous fistulas vary between 10.7% and 16%. In contrast, the rate of arteriovenous fistula originating from two coronary arteries is 5% [3,4]. While bilateral fistulae end in 56% of the pulmonary arteries, 17% of the single arteriovenous fistulas terminate in the pulmonary artery [3]. Different types of arterio-venous fistulae are described in the literature. If this case is different, two separate fistulae from single coronary artery have emerged. This is extremely rare. Coronary arteriovenous fistulas are rare, difficult to detect, may be associated with other coronary artery anomalies and are usually congenital [2,3,5]. Acquired coronary fistulas are caused by atherosclerosis, tachycardia and trauma [6,8,10]. In addition, 20% of patients with congenital coronary arteriovenous fistulas have another congenital or acquired heart disease [1,2,4]. Treatment in asymptomatic adults and nonspecific shunts is controversial. Successful results of catheter closure of the fistula have been reported [9,10]. However, as in this case, it is not possible to close each case percutaneously. In this case, both fistulas originated from the same coronary artery, and the procedure was unsuccessful due to their anatomic position. It would be appropriate to safely transfer such cases to surgical clinics. It will be the right choice to decide which surgical method to choose according to the clinical experience of the surgical team, the accompanying pathologies and whether or not it is complex. CONCLUSIONS It is possible and preferable to safely close the fistula in the heart with off pump technique in patients which are not complex and have no accompanying cardiac pathologies. Figure 2 Failed percutan coil embolisation. Figure 3 The appaerance closure fistulas in the operation area. Central Yasa et al. (2017) Email: Ann Vasc Med Res 4(4): 1062 (2017)3/3Yasa H, Aktuğ F (2017) Dual Fistula Origınating from Left Anterior Descending Coronary Artery; Off-Pump Surgical Closure Technique. Ann Vasc Med Res 4(4):1062.Cite this articleREFERENCES 1. Fernandes ED, Kadivar H, Hallman GL, Reul GJ, Ott DA, Cooley DA.Congenital malformations of the coronary arteries: the Texas HeartInstitute experience. Ann Thorac Surg. 1992; 54: 732-740. 2. Bauer EP, Piepho A, Klovekorn WP. Coronary arteriovenous fistula:surgical correction of a rare form. Thorac Cardiovasc Surg. 1994; 42:237-239. 3. Baim DS, Kline H, Silverman J. Bilateral coronary artery-pulmonaryartery fistulas. Circulation. 1982; 65: 810-815. 4. Levin DC, Fellows KE, Abrams HL. Hemodynamically significantprimary anomalies of the coronary arteries: angiographic aspects.Circulation. 1978; 58: 25-34. 5. Gupta NC, Beauvais J. Physiologic assessment of coronary arteryfistula. Clin Nucl Med. 1991; 16: 40-42. 6. Jiang B, Yang Y, Li F, Ma N, Wu S, Li R, et al. Giant aneurysm ofright coronary artery fistula into left ventricle coexisting withnoncompaction of left ventricular myocardium. Ann Thorac Surg.2014; 98: e85-86.7. Vitarelli A, De Curtis G, Conde Y, Colantonio M, Di Benedetto G,Pecce P, et al. Assessment of congenital coronary artery fistulas bytransesophageal color Doppler echocardiography. Am J Med. 2002;113: 127-133. 8. 6. Said SA, van der Werf T. Acquired coronary cameral fistulas: arethese collaterals losing their destination? Clin Cardiol. 1999; 22: 297-302. 9. Wu S, Fan C, Yang J. A rare, giant coronary artery ectasia coexistingwith a coronary artery fistula in an older infant. Cardiology in theYoung. 2017; 27: 1-3. 10. Ercan E, Tengiz I, Yakut N, Gurbuz A, Bozdemir H, Bozdemir G.Takayasu’s arteritis with multiple fistulas from three coronaryarteries to lung paranchima. Int J Cardiol. 2003; 88: 319-320. 11. Qureshi SA, Tynan M. Catheter closure of coronary artery fistulas. JInterv Cardiol. 2001; 14: 299-307. 12. Alekyan BG, Podzolkov VP, Cardenas CE. Transcatheter coilembolization of coronary artery fistula. Asian Cardiovasc Thorac Ann.2002; 10: 47-52.