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.
Fistula-2017-0.mp4
Fistula-2017-SVG-0.mp4
Fistula-2017-0.mp4 Fistula-2017-SVG-0.mp4Relevant 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
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.mp4Relevant 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
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.mp4Interventional 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.
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
In antegrade injection, it appeared as proximal LAD was totally occluded as blood flow into the 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.mp4Case 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.
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.