JACC

Lots of interesting abstracts and cases were submitted for TCTAP 2022. Below are the accepted ones after a thorough review by our official reviewers. Don¡¯t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!

TCTAP C-018

¡°Double Steal Phenomenon¡± : A Rare Case of Coronary Fistula From LAD to Main Pulmonary Artery in the Presence of SVG to LAD

By Zul Hilmi Yaakob

Presenter

Zul Hilmi Yaakob

Authors

Zul Hilmi Yaakob1

Affiliation

KPJ Tawakkal Specialist KL, Malaysia1,
View Study Report
TCTAP C-018
CORONARY - Adjunctive Procedures (Thrombectomy, Atherectomy, Special Balloons)

¡°Double Steal Phenomenon¡± : A Rare Case of Coronary Fistula From LAD to Main Pulmonary Artery in the Presence of SVG to LAD

Zul Hilmi Yaakob1

KPJ Tawakkal Specialist KL, Malaysia1,

Clinical Information

Patient initials or Identifier Number

NAM

Relevant Clinical History and Physical Exam

54 year old lady with Diabetes Mellitus and Hypertension since 2014. She had Coronary artery bypass graft (CABG) surgery on23/1/2009 at another private hospital where single vessel grafting (SVG) to LAD was done. She first saw me in November 2015  and well until July 2017 when she started to have chest pain + shortness of breath on exertion. DSE was positive.Coronary angiogram and graft study was performed - PCI to LAD and LCX done. Coronary fistula was noted from LAD to PA. 


Fistula-2017-0.mp4
Fistula-2017-SVG-0.mp4

Relevant Test Results Prior to Catheterization

At the time decision was made not to intervene as symptoms was thought to be due to LAD and LCX diseases. SVG to LAD was widely patent with some retrograde flow into the fistula.  
She presented as outpatient on 15th August 2021 with progressive worsening of shortness of breath since early July 2021.  In early Stage II of Treadmill ECG test, she had severe dyspnoea and fell down. No ECG changes noted. 
CT coronary angiogram was done - coronary fistula from LAD to main PA.
Fistula-10.mp4
Fistula-20.mp4

Relevant Catheterization Findings

We proceeded to coronary angiogram on 20th August 2021 which revealed patent stents in LAD and LCX. 
Coronary fistula now is much larger than in 2017. 
SVG to LAD also drained retrogradely to the fistula in combination with antegrade LAD flow. 
Coiling procedure was performed with two Penumbra Ruby coils 4.0 mm x 15 cm and 3.0 mm x15 cm which were delivered through 2.6F PX Slim microcatheter. 
Post coiling angiogram showed much reduced flow in the fistula. 
Patient reported instantaneous relieve. 
Fistula-8-post-coiling0.mp4
Fistula-9-post-coiling0.mp4

Interventional Management

Procedural Step

Coronary angiogram on 20thAugust 2021 revealed patent stents in mid LAD and mid LCX. Large fistula was noted from proximal LAD into main pulmonary artery. Flow and size of fistula vessel network were larger than that in 2017. SVG to LAD was patent but showed progressive higher retrograde flow in the proximal LAD fistula into pulmonary artery in comparison with that in 2017. 
In antegrade injection, it appeared as proximal LAD was totally occluded as blood flow into the fistula. This phenomenon was likely due to combined factors of competitive flow from the SVG to LAD plus the existence of the large fistula.
She decided against having another open heart surgery thus we proceeded with percutaneous intervention. Coiling procedure was performed with two Penumbra Ruby coils 4.0 mm x 15 cm and 3.0 mm x 15 cm which were delivered through 2.6F PX Slim microcatheter. 
Post coiling angiogram showed much reduced flow in the fistula. 
Immediately after the procedure patient felt better. She described it as new ¡®feeling relieved¡¯ in term of her breathing since many years ago. 
Fistula-7-microcatheter0.mp4
Fistula-10-post-coiling0.mp4

Case Summary

Although rare coronary fistula is an important cause of myocardial ischaemia. 
The presence of SVG to LAD in this case did not reduce her symptoms as large volume of retrograde flow from SVG-LAD went into the fistula. 
This may have contributed to progression of the fistula network due to increased flow from both LAD and SVG to LAD. 
Coronary fistula can be successfully closed percutaneously using coiling device.