Andersons pediatric cardiology 1332
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FIG.50.21 Sequelaeaftertreatmentofcoronaryarteryfistula(CAF).
Moderate-sizeddistalleftanteriordescending(LAD)fistuladrainingintothe
leftventricle,showingmoderatelydilatedconduitLAD(A).Aftercoil
occlusion,afollow-upangiogram6monthslaterdemonstratedoptimal
remodelingwithdecreaseinconduitLADcalibertonormal(B,white
arrows).Moderatetolargedistalleftcircumflexfistulatotherightventricle,
withthethirdobtusemarginalbranchnotedproximaltothedrainagesite
(C,whitearrow).Aftercoilocclusionatthedrainagepoint,therewasclot
formationinthedilatedleftcircumflexarteryoccludingthethirdobtuse
marginalbranch(D,thickwhitearrow)12hoursafterclosure,causing
acutemyocardialinfarction.Thethirdobtusemarginalbranchisnotvisible
duetoocclusion(smallwhitearrow).Largedistalrightcoronaryartery
fistuladrainingtotherightventricle(E).Aftersurgicalocclusionatthe
drainagepoint,afollow-upangiogram2yearslaterdemonstrated
asymptomaticthrombosisoftheentirerightcoronaryartery,withevidence
ofrevascularizationwiththreadlikevessels(F,whitearrows).Largedistal
dilatedtortuousrightcoronaryarteryfistulashowingpersistentcoronary
dilation(whitearrows)atbaseline(G).Atfollow-upangiogram10years
later,persistentcoronarydilationsecondarytopartialspontaneousclosure
ofthefistulawithasmallamountofresidualflow(H,whitearrows).
Follow-upcoronaryanatomicandfunctionalevaluationbyGowdaand
colleaguesafterCAFclosuredemonstratedposttreatmentsequelaetoinclude
(seeFig.50.21):(1)remodelingofthefistulaand/orconduitcoronaryartery
segmentwithuniformdecreaseincoronaryarterysizetowardnormal(favorable
remodeling)orareasofdiscreteintimalstenosis(unfavorableremodeling),(2)
persistentcoronarydilationinpatientswithresidualflow,(3)asymptomaticor
symptomaticthrombosis(myocardialinfarction)oftheproximalconduit
coronaryarteryoccludingnormaladjacentcoronarybranches,and(4)the
thrombosedvesselshowedthreadlikerevascularization,aswellascollateral
vesselformationfromadjacentbranches.Basedontheirinstitutionalexperience
andextensivereviewofliterature,theyidentified25patientswithreported
coronaryarteryeventsfollowingCAFclosure.Fromtheavailabledatafor
review,14of16patientswithcoronaryeventshadlargesizeanddistalCAF.
Althougholderpatientswereathigherrisk,evenyoungerpatientswithlarge
distalCAFdemonstratedsymptomaticandasymptomaticcoronarythrombosis.
PartialclosureoflargedistalCAFinsymptomaticpatients(Fig.50.22)hasbeen
recentlyadvocatedbyafewclinicians(author'sexperienceandpersonal
communications)tomitigatetheriskofpostclosureacuteorchroniccoronary
event/coronarythrombosiscausingmyocardialinfarction.Partialclosurecan
eliminatethehemodynamicburden,whileallowingpersistentresidualflowand
thuspreventingtheriskofstasisandthrombosisinlargedistalCAFs.
FIG.50.22 Partialclosureofcoronaryarteryfistula(CAF).Moderatesizeddistalleftanteriordescending(LAD)fistulawithrestrictionatthe
drainagesite(A,arrow)andlargerightcoronaryarterydistalfistulawith
restrictionandminimalcontrastflowatthedrainagesite(B,arrow)
demonstratenaturalspontaneouspartialclosure.Alargedistalright
coronaryfistula(C)waspartiallyclosedusingacoilshowingminimal
residualflow(D,arrow).
Therefore,basedonknowledgeofthepostclosuresequelaeandriskfactorsfor
coronaryevents,amodifiedcontemporaryapproachtothemanagementofCAF
isillustratedinFig.50.23.112Insummary,medicalobservationandno
interventionarerequired(transcatheterorSC)forsmall-sizeproximalanddistal
