Iatrogenic Aortocoronary Arteriovenous Fistula Percutaneous Management of a Surgical Complication

atrogenic aortocoronary arteriovenous fistula(ACAVF) resulting from placement of an arterialgraft to a cardiac vein is a rare complication ofcoronary artery bypass grafting (CABG)(1,2).Mostpa-tients present post-operatively with angina as a resultof residual ischemia that is due to either an unby-passed artery or a coronary steal syndrome (CSS). A74-year-old woman presented with recurrence ofangina with a history of multivessel coronary arterydisease status post-CABG in 2006 with a left internalmammary artery (LIMA) Y graft to the left anteriordescending andfirst diagonal coronary arteries, andsequential saphenous vein graft (SVG) to the circum-flex obtuse marginal (OM) and the posterior descend-ing artery (PDA), and recurrent angina secondary toan occluded SVG resulting in a second CABG with afree radial graft anastomosed to the LIMA and thenplaced sequentially to the OM and PDA. Coronaryangiography showed that the radial graft was inreality anastomosed to the left circumflex vein(Figures 1A and 1B). This iatrogenic fistula resultedin a dilated tortuous LIMA and radial grafts withpossible CSS that explained the ischemia. Given thatthe patient was not a candidate for a third surgeryand that medical therapy was not controlling hisangina, a decision for percutaneous closure wasmade. An initial attempt with coil embolization ofthe coronary vein was unsuccessful because theinterlock coils did not deploy appropriately. Adeployment of a 3-mm Amplatzer Vascular Plug II(St. Jude Medical, Saint Paul, Minnesota) was suc-cessful, with no residualflow into the coronary sinusfrom the radial graft (Figures 1C–1F). In summary,ACAVF is a rare, but serious, complication of CABGthat may result in ischemia secondary to CSS orhigh-output heart failure when a significant degreeof left-to-right shunting develops over time. Percuta-neous closure by embolization with either detachableballoons or coils(3), or deployment of a vascular plugoffers an effective and safe management for symp-tomatic patients.