CRP2.A Novel Hybrid Approach to Correct a Giant Aneurysmal Coronary Artery Fistula in An Adult Male Patient
Presented During: AATS Cardiothoracic Resident Case Report-Poster Display
King Abdulaziz University
Canada - Contact Me
Completing Cardiac Surgery residency at the end of this academic year 2023 at Dalhousie University, Halifax, Canada. Interested in becoming a valve specialist, which includes valve repair and transcatheter procedures.
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Los Angeles Convention Center
Room: ePoster Area, Exhibit Hall
Description
A 37-year-old male presented with supra-ventricular tachycardia, exercise intolerance and lower limb edema. He reported a 2-year history of dyspnea and palpitations with signs of SVC-Syndrome. Computed tomography angiography (CTA) showed a gigantic 15cm fistula aneurysm caused almost complete obstruction of the superior vena cava (SVC), inferior vena cava (IVC), right pulmonary veins and right pulmonary artery (RPA).
The Achilles heel of surgical coronary arteriovenous fistula (CAVF) ligation is myocardial protection. A hybrid approach was utilized to overcome this issue. The fistula was occluded using a percutaneous plug device and subsequently resecting the aneurysm on cardio-pulmonary bypass (in order to ensure adequate myocardial protection). Using a telescoping technique, the 14mm plug was deployed proximal to the fistula aneurysm, angiographically occluding flow through the fistula and aneurysm.
Subsequently, sternotomy was performed on cardiopulmonary bypass (CPB) via peripheral cannulation as the aneurysm was adjacent to the sternum. Successful antegrade cardioplegic arrest occurred without the need to manually occlude the fistula (plug resistance to flow). The fistula aneurysm was opened between the SVC and aorta. All accessible aneurysmal free wall tissue was resected. The fistula inlet and outlet were identified and primarily closed. The patient was weaned off CPB with normal biventricular function.
The patient was discharged on warfarin and ASA for embolic prophylaxis. Eight-month postoperative CTA showed resolution of all obstruction and normalization of heart size. The patient was completely asymptomatic at follow up with no further palpitations.
The Achilles heel of surgical coronary arteriovenous fistula (CAVF) ligation is myocardial protection. A hybrid approach was utilized to overcome this issue. The fistula was occluded using a percutaneous plug device and subsequently resecting the aneurysm on cardio-pulmonary bypass (in order to ensure adequate myocardial protection). Using a telescoping technique, the 14mm plug was deployed proximal to the fistula aneurysm, angiographically occluding flow through the fistula and aneurysm.
Subsequently, sternotomy was performed on cardiopulmonary bypass (CPB) via peripheral cannulation as the aneurysm was adjacent to the sternum. Successful antegrade cardioplegic arrest occurred without the need to manually occlude the fistula (plug resistance to flow). The fistula aneurysm was opened between the SVC and aorta. All accessible aneurysmal free wall tissue was resected. The fistula inlet and outlet were identified and primarily closed. The patient was weaned off CPB with normal biventricular function.
The patient was discharged on warfarin and ASA for embolic prophylaxis. Eight-month postoperative CTA showed resolution of all obstruction and normalization of heart size. The patient was completely asymptomatic at follow up with no further palpitations.