Author + information
- Received August 10, 2017
- Accepted August 22, 2017
- Published online December 4, 2017.
- aDepartment of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, People’s Republic of China
- bDepartment of Radiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- ↵∗Address for correspondence:
Dr. Ge-Jun Zhang, Department of Radiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People's Republic of China.
Although the treatment of end-stage heart failure includes multiple drugs, cardiac assist devices, and heart transplantation, the overall prognosis is still not optimistic (1). We present a patient who underwent drug treatment for 10 years for heart failure and later diagnosis as an arteria iliaca communis–venae cava inferior fistula. The fistula was successfully closed using a transcatheter technique, and the enlarged heart reverted to normal size.
A 42-year-old man with the diagnosis of dilated cardiomyopathy had dyspnea for 10 years. Heart transplant surgery was suggested for the patient because of poor response to drug treatment. The patient had a history of abdominal trauma 20 years earlier. During the physical examination, abdominal murmur was detected. The chest radiograph (Figure 1) and computed tomography (Figure 2) examination were performed in our hospital. Thus, the diagnosis was confirmed as an arteria iliaca communis–venae cava inferior fistula. After informed consent was obtained from the patient’s family members, cardiac catheterization was performed under local anesthesia with fluoroscopic guidance. Follow-up chest radiograph (Figure 3) and computed tomography (Figure 4) 6 months later showed normal heart size accompanied by significantly attenuated symptoms of heart failure.
Angiography showed that the diameter of the fistula was 12 mm (Figure 5). The fistula was crossed in a retrograde fashion from the aorta using a 5-F Judkins right coronary catheter. A 0.035-inch glide wire was advanced into the inferior vena cava and exteriorized out of the femoral vein. A 9-F catheter patent ductus arteriosus delivery sheath (Lifetech Scientific, Shenzhen, China) was advanced in an antegrade manner into the descending aorta. A 16/14 mm patent ductus arteriosus occluder device (Lifetech Scientific) was deployed to close the fistula (Figure 6). The patient is doing well with good device position and no residual leak on computed tomography through 6-month follow-up.
Aortocaval fistula is an abnormal connection between the arterial and venous system that may be congenital or acquired (2,3). With the increase in various diagnostic, interventional, or surgical procedures, the incidence of aortocaval fistula has increased (4). Diagnosis before surgery is desirable because it allows preparation by the surgeon for appropriate operative techniques. In 1 series, mortality was 15% if diagnosis was made before surgery in contrast to 100% mortality if it is not (5).
Although great progression of treatment has been made for end-stage heart failure, the prognosis is still poor. We confirmed the existence of arteriovenous shunt through careful medical history and physical examination. In considering how to deal with the arteriovenous fistula, some experts have suggested the application of a stent graft (6). However, there were 2 main reasons why we chose a patent ductus arteriosus occluder instead. The first is that deployment of stent graft might lead to malapposition because of the difference between the anterior and posterior lumen. The second is the greater economic burden of stent graft is greater.
This is the first reported case, to the best of our knowledge, of treatment of end-stage heart failure by transcatheter closure of arteria iliaca communis–venae cava inferior fistula caused by traumatism. After 6 months of follow-up, the patient is doing well without additional problems.
In conclusion, our limited experience demonstrates that device closure of a fistula-related heart failure is feasible, safe, and effective.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 10, 2017.
- Accepted August 22, 2017.
- 2017 American College of Cardiology Foundation
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