Iatrogenic left internal mammary artery-coronary vein anastomosis treated with covered stent deployment via retrograde percutaneous coronary sinus approach.

OBJECTIVES: Percutaneous treatment of acquired coronary fistula with covered stent

BACKGROUND: Acquired aorto-coronary fistulae (ACF) is a rare complication of coronary artery bypass graft (CABG) surgery. Surgical repair has been generally recommended, but percutaneous techniques have also been described; coils were used primarily in smaller fistula while double umbrella or vascular occlusion devices were used in larger ones. To the best of our knowledge the use of coronary covered stent has never been reported. A 73-year-old man underwent CABG in November 2004 for unstable angina and left internal mammary artery (LIMA) was anastomosed to left anterior descending (LAD) coronary artery. Three months later he underwent a control angiogram to check for the reappearance of effort angina, which demonstrated an inadvertent LIMA-great cardiac vein (GCV) anastomosis. After discussions, an attempt to close the ACF with implantation of a covered stent was performed.

METHODS: Using a percutaneous right internal jugular vein approach, coronary sinus was selectively cannulated and a 0.014-in. coronary guide wire was advanced selectively to the GCV, then a covered stent was deployed across the anastomotic site, obtaining the immediate occlusion of the ACF.

RESULTS: No contrast medium flowed into the distal part of the GCV at the reinjection of the coronary sinus and a selective injection into LIMA showed the absence of flow through LIMA, confirming the occlusion of the anastomotic site.

CONCLUSIONS: We have demonstrated successful occlusion of an iatrogenic ACF by using percutaneous stenting of GCV with covered stent via coronary sinus approach, which seems to be technically less demanding, safer, and time sparing.