Balloon Anchor Technique to Aid Closure of Coronary Fistula Using Vascular Plug.

Coronary arteriovenous fistulas (CAFs) are abnormal communications between coronary arteries and cardiac chambers or great vessels.1 They are usually congenital but may be acquired after trauma, surgery, or percutaneous procedures. Although often incidental in childhood, hemodynamically significant CAFs in adults can cause myocardial ischemia, arrhythmia, heart failure, or endarteritis.2 Evidence to guide management is limited, and multidisciplinary evaluation at centers experienced in both percutaneous and surgical approaches is recommended.3 A 60-year-old man with hypertension and prior left anterior descending coronary artery stenting presented with worsening chest pain that progressed to unstable angina. A coronary angiogram showed a new middle right coronary artery stenosis that was treated with a stent. Coronary angiography identified a high-flow fistula from the proximal right coronary artery draining into the superior vena cava. Persistent symptoms, right-sided chamber enlargement, and a Qp:Qs of 1.5 indicated a significant shunt and functional ischemia from coronary steal. Initial attempts to deploy a 6-mm Amplatzer Vascular Plug II failed due to inadequate catheter support across a tortuous tract. An anchoring balloon technique aid, permitting delivery and successful deployment of the AVP II at the arterial origin with complete angiographic occlusion. CAFs are a rare but treatable cause of angina and myocardial ischemia. Management should be individualized and planned by a multidisciplinary Heart Team. Transcatheter closure is effective in suitable anatomies, and balloon-assisted anchoring is a useful technique to facilitate device delivery in elongated or tortuous fistulas.