Ann Thorac Surg 2004;78:2193-2195
© 2004 The Society of Thoracic Surgeons
How to do it
Improvement of Coronary Artery Fistula Surgery by Intraoperative Imaging
Per Kristian Hol, MDa,*,
Odd Geiran, MD, PhDb,
Kai Andersen, MD, PhDb,
Karleif Vatne, MDc,
Jon Offstad, MD, PhDd,
Jan Ludvig Svennevig, MD, PhDb,
Erik Fosse, MD, PhDa
a The Interventional Centre, Rikshospitalet University Hospital, Oslo, Norway
b Department of Thoracic and Cardiovascular Surgery, Rikshospitalet University Hospital, Oslo, Norway
c Department of Radiology, Rikshospitalet University Hospital, Oslo, Norway
d Department of Cardiology, Rikshospitalet University Hospital, Oslo, Norway
Accepted for publication October 8, 2003.
* Address reprint requests to Dr Hol, The Interventional Centre, Rikshospitalet University Hospital, N-0027 Oslo, Norway
per.kristian.hol{at}rikshospitalet.no
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Abstract
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Complete surgical closure of coronary artery fistulas may be difficult because of complex anatomy and often multiple sites of origin. This study therefore assessed whether intraoperative fistula imaging would contribute to and improve the final surgical result. Seven adult patients underwent operation for coronary arteriovenous fistula during a 10-year period. In all 4 patients who had image guidance, the operation was guided by immediate imaging to achieve complete and persistent closure. In contrast, 2 of 3 patients who underwent operation without image guidance had residual left-to-right shunts at follow-up. Image guidance was helpful and increased the success rate of surgical closure of coronary artery fistulas.
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Introduction
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Since the first description of successful surgical treatment of a coronary artery fistula in 1947 [1], few series are available, and most of them are case reports with limited information on the recurrence of fistula after operation based on angiographic follow-up [2–4]. Cheung and colleagues [4] reported that postoperative angiography was performed in 50% of their cases, and recurrence was noted in approximately 20%. Complete fistula closure can be challenging because of complex anatomy: often multiple entrance sites are difficult to define. The localization of the arterial inflow to the fistula at the posterior part of the heart can be particularly difficult to survey. New imaging modalities in the operating theater may allow intraoperative assessment of the fistula closure, potentially contributing to and improving the therapeutic result. In this study my colleagues and I compared patients who underwent operation for coronary artery fistulas guided by on-table angiography, transesophageal echocardiography, or both with those who underwent operation without intraoperative imaging.
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Technique
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Between 1992 and 2002, 7 adult patients (4 men and 3 women) with a median age of 54 years (range, 43 to 67 years) were treated surgically for coronary artery fistula. Before operation angina pectoris was the most frequent symptom. Preoperative examinations included electrocardiography, echocardiography, magnetic resonance imaging, and selective coronary angiographic studies. The fistula was approached from the epicardial side except in 2 patients, in whom the pulmonary artery was opened for closure of the fistulous outflow site. Cardiopulmonary bypass was used in all patients but 1. Intraoperative coronary angiography for guidance of the surgical procedure was available in the last 4 patients, with additional transesophageal echocardiography in 1 of them. Follow-up of all patients included exercise electrocardiography, dobutamine stress echocardiography, and selective coronary angiography.
Six of 7 patients had fistulas with multiple origins from 1 or 2 main coronary vessels. In 4 patients, the fistulas drained into the pulmonary artery, and in 3 they drained into the coronary sinus or the atria. Five patients had, except for the coronary fistulas, normal coronary vessels, whereas 2 had additional 3-vessel coronary artery disease.
In the last 4 patients, intraoperative angiography was used as a guide during operation; in 1 of them this was also supplemented by transesophageal echocardiography. The use of intraoperative imaging led to additional operative correction in all cases and was essential for an optimal result. The first patient had widely dilated left main and circumflex arteries ending in the coronary sinus. The fistula was ligated close to the sinus, but intraoperative angiography demonstrated another fistula in the same area. Repeat on-table angiography helped to identify this fistula as it originated from the circumflex artery, after which successful ligation was performed. The second patient had fistulas from the left and right coronary arteries draining to the left atrium. After closure, on-table angiography revealed additional fistulas that were subsequently closed, as confirmed by repeat on-table angiography. The third patient (Fig 1), who was previously treated unsuccessfully with percutaneous stent closure, had fistulas from the left and right coronary arteries draining to the pulmonary artery. After attempted closure, intraoperative angiography demonstrated an additional fistula that was then successfully obliterated. The fourth patient had a large and dilated fistula from the left coronary artery that ended in the coronary sinus and right atrium. Angiography had difficulty demonstrating the entry site of this fistula. With the help of transesophageal echocardiography the distal end was identified and successfully ligated. Intraoperative angiography verified an excellent result with no additional fistulas present.
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Fig 1. Patient with multiple fistulas to the pulmonary artery. (A) Preoperative angiography demonstrated fistulas from both the left anterior descending and the circumflex arteries (arrow). (B) After surgical closure of numerous fistulas, intraoperative angiography identified a persisting fistula from the circumflex artery (arrowheads), which was then successfully closed. (C) At follow-up after 3 months, all fistulas were closed, and the patient was free of symptoms.
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Follow-up examination was performed at a mean of 55 months (range, 3 to 130 months). None of the 4 patients who underwent operation with image guidance had a residual fistula, and all were asymptomatic. Of the 3 patients who underwent operation without angiographic guidance, 1 was asymptomatic with no residual fistula present, but the other 2 demonstrated persistent fistulas. One of these had minor symptoms and will be followed up by angiography. The other, with persistent fistulas from the left anterior descending artery, had remaining symptoms of angina and dyspnea. Percutaneous coiling was performed, but there was no reduction in shunting. The patient did not want an additional operation and is being followed up clinically. All patients had normal stress tests at follow-up.
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Comment
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Our material clearly demonstrated a beneficial effect of intraoperative image guidance during closure of coronary artery fistulas. Complete closure at follow-up was found in 4 patients in whom operation was performed with intraoperative imaging. In 3 of these patients intraoperative angiography revealed additional fistulas that were successfully closed and otherwise would have been missed. In the fourth patient closure was achieved after transesophageal echocardiography. Two of 3 patients who underwent operation without image guidance had persistent fistulas at follow-up. We therefore consider intraoperative imaging to be a necessary adjunct for the surgical treatment of coronary artery fistulas.
Intraoperative angiography can be performed with a portable C-arm or with fixed angiographic equipment installed in the operating room [5]. With fixed angiographic equipment in the operating room, intraoperative angiography is easily available, and multiplanar views with high-quality images can be obtained.
Intraoperative image guidance by transesophageal echocardiography was superior to angiography in 1 patient. Because of the high flow through the markedly dilated fistula, the angiographic contrast agent was too diluted, and this caused inadequate visualization of the drainage into the coronary sinus and right atrium. Transesophageal echocardiography nicely demonstrated the location of the fistula during operation and guided the closure. Thus, transesophageal echocardiography and angiography may be complementary methods for on-table demonstration of these lesions.
In conclusion, intraoperative imaging ensures complete surgical closure of coronary fistulas that otherwise might be difficult because of complex anatomy and multiple sites of origin.
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References
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- Biörck G, Crafoord C. Arteriovenous aneurysm on pulmonary artery simulating patent ductus arteriosus Botalli. Thorax. 1947;2:65–74
- Rittenhouse EA, Doty DB, Ehrenhaft JL. Congenital coronary artery-cardiac chamber fistula. Review of operative management. Ann Thorac Surg. 1975;20:468–485[Abstract]
- Mavroudis C, Backer CL, Rocchini AP, Muster AJ, Gevitz M. Coronary artery fistulas in infants and children: a surgical review and discussion of coil embolization. Ann Thorac Surg. 1997;63:1235–1242[Abstract/Free Full Text]
- Cheung DL, Au WK, Cheung HH, Chiu CS, Lee WT. Coronary artery fistulas: long-term results of surgical correction. Ann Thorac Surg. 2001;71:190–195[Abstract/Free Full Text]
- Fosse E, Hol PK, Samset E, Røtnes JS, Bjørnstad P, Lundblad R. Integrating image-guidance into the cardiac operating room. Minim Invasive Ther Allied Technol. 2000;9:403–409
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Abstract
Introduction
