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Ann Thorac Surg 2000;69:1973-1982
© 2000 The Society of Thoracic Surgeons

Current review

Traumatic coronary artery fistula management

Camille Hancock Friesen, MDa, Jonathon G. Howlett, MDb, David B. Ross, MDa

a Division of Cardiac Surgery, Dalhousie University, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
b Division of Cardiology, Dalhousie University, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada

Address reprint requests to Dr Ross, IWK Grace Health Centre, PO Box 3070, Halifax, NS, B3J 3G9 Canada
e-mail: dross{at}iwkgrace.ns.ca


   Abstract
Top
 Abstract
Introduction
 Case presentation
 Literature review
 Comment
 References
 
Traumatic coronary artery-cameral fistulas (TCAF) are uncommon sequelae of trauma that require early surgical intervention to prevent complications. The etiology of traumatic coronary artery-cameral fistulas may be classified as accidental or iatrogenic and have distinctly different courses depending on the etiology. The two operations described for definitive surgical closure of a traumatic coronary-cameral fistula are external ligation/obliteration of the fistula (with or without bypass grafting to the coronary artery distal to the fistula) and direct repair of the fistula from within the recipient chamber. The technique of fistula closure from within the recipient chamber is associated with a reduced incidence of fistula recurrence. A case report and a collective literature review are presented.


   Introduction
Top
 Abstract
 Introduction
Case presentation
 Literature review
 Comment
 References
 
Previous reviews of case reports of the treatment of traumatic coronary artery-cameral fistulas (TCAF) in the literature have clearly outlined that early operative intervention is preferable to delayed intervention as patients may develop life-threatening morbidity while being managed conservatively [1]. There are two described operative techniques for fistula repair: external ligation/obliteration of fistula with or without distal coronary artery bypass grafting, and closure of fistula from within the recipient chamber. There has been a trend over time to repair from within the recipient chamber, but there have been no comparisons of the morbidity associated with the two surgical options. We present a case of a traumatic coronary artery fistula with repair from within the recipient chamber and present the reports published to date of coronary artery-to-cardiac chamber fistulas treated surgically.

A comprehensive literature search was performed (Medline 1958 to 1998; PubMed) for English literature pertinent to the operative management of traumatic coronary artery fistula (key words searched included coronary artery fistula, trauma, acquired coronary artery fistula, coronary-cameral fistula). Cases were excluded if there was an arteriovenous fistula rather than a coronary-cardiac chamber (cameral) fistula. The literature was analyzed with specific attention to the evolution of operative technique and its relationship to outcome. We compared the findings of the literature review with a recent case at our institution.


   Case presentation
Top
 Abstract
 Introduction
 Case presentation
Literature review
 Comment
 References
 
A 25-year-old male assault victim was intubated and transferred to the New Halifax Infirmary by ambulance for assessment and treatment of two stab wounds to the right lateral chest. Prehospital, the patient was comatose with a palpable radial pulse at a rate of 110 beats per minute with no ausculable blood pressure. On presentation to hospital, the patient developed pulseless electrical activity. An emergency right thoracotomy was performed and a large hemothorax was evacuated and pericardial tamponade was relieved. Spontaneous electromechanical activity resumed. A 1-cm laceration was noted in the right ventricle near the atrioventricular groove and repaired with a 3.0 Prolene suture (Ethicon, Somerville, NJ). After closure of the thoracotomy, the patient continued to bleed significantly (600 mL in 1 hour), so he was taken to the operating room for formal exploration. The thoracotomy incision was reopened and a 4-cm laceration in the right middle lobe of the lung was repaired primarily. The incision was reclosed after hemostasis had been secured. The patient was extubated on the first postoperative day. A routine posttrauma transthoracic echocardiogram on postoperative day 2 showed moderate tricuspid regurgitation.

On postadmission day 10, a continuous murmur was heard and a repeat transthoracic echocardiogram was performed to rule out endocarditis. This revealed severe tricuspid regurgitation and an apparent aorto-right ventricle fistula with moderate left-to-right shunt. At subsequent cardiac catheterization with selective coronary arteriography, a right coronary artery to right ventricle fistula was correctly identified with >=4 tricuspid regurgitation, left-to-right shunt of 1.5:1, ejection fraction of 77%, right atrial pressure of 5 mm Hg, and an a wave equal to the v wave at 10 mm Hg. Mean pulmonary artery pressure was 16 mm Hg and left ventricular end diastolic pressure was 14 mm Hg (Fig 1).



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  		Fig 1. Selective right coronary artery injection angiogram; proximally dilated RCA decompresses into right ventricle (arrowheads) at the site of the RCA-RV fistula.

 
The patient was reoperated on postadmission day 14. A conventional median sternotomy was performed and the patient was placed on cardiopulmonary bypass with bicaval venous and aortic cannulation. Antegrade cold, high-potassium blood cardioplegia was administered via the aortic root. The right atrium was opened and retrograde cardioplegia was administered via the coronary sinus. The right coronary artery, dilated to approximately 10 mm, was identified in the edematous pericardium proximal to the repair suture just distal to the atrioventricular groove. The right coronary artery was opened longitudinally in its midportion and was probed with a 2-mm probe. Longitudinal dissection along the ventral surface of the artery continued to its junction with the wall of the right ventricle, which was opened. The probe was seen entering the right ventricle through the fistula. With the probe still in the artery, we repaired the fistula from within the right ventricle in two layers with 7-0 Prolene. The artery was probed to ensure that no stenosis had developed with the repair and then closed primarily with 7-0 Prolene in the same orientation it had been opened. The tricuspid valve injury was a 1.5-cm rent at the junction between the posterior leaflet and the annulus, and it was repaired with 5-0 Prolene. The patient weaned from cardiopulmonary bypass without difficulty. Postoperatively, the patient remained asymptomatic with a grade I/VI ejection systolic murmur at the left sternal border. A repeat transthoracic echocardiogram on postadmission day 16 showed no evidence of a fistula, moderate tricuspid regurgitation, and right ventricle mild enlargement with normal systolic function. The left ventricle was normal. The patient was discharged on postadmission day 19 after antibiotics had been discontinued. He was seen in follow-up 6 weeks postdischarge, and at that time he was asymptomatic with no murmur and no clinical evidence of right heart failure. No investigations were performed because of the absence of any clinical stigmata of recurrent pathology.


   Literature review
Top
 Abstract
 Introduction
 Case presentation
 Literature review
Comment
 References
 
Thirty patients with surgically repaired accidental TCAF have been described in the English literature since 1958 (including the patient reported herein) [1–29] (Table 1). Six patients with conservatively managed accidental TCAF have also been reported [30–35] (Table 2). The literature recording iatrogenic TCAF includes reports of 81 cases (Tables 3–5) [36–55]. Accidental TCAF and iatrogenic TCAF appear to be very dissimilar entities and they will be considered separately.


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  		Table 1. Surgically Treated Traumatic Coronary Artery Fistulas: 1958 to 1998

 

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  		Table 2. Conservatively Treated Traumatic Coronary Artery Fistulas: 1958 to 1998

 

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  		Table 3. Iatrogenic Coronary Artery Fistulas (Postoperative): 1958 to 1998

 

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  		Table 4. Iatrogenic Coronary Artery Fistulas (Postendomyocardial Biopsy): 1958 to 1998

 

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  		Table 5. Iatrogenic Coronary Artery Fistulas (Postpercutaneous Transluminal Coronary Angioplasty): 1958 to 1998

 
Accidental traumatic coronary artery fistulas
There is a wide range in the reported interval from injury to definitive fistula closure (range 1 week to 36 years). The average interval from injury to definitive fistula closure has decreased (in the decade 1960 to 1969, the mean interval was 65.8 to 71 months; in the decade 1990 to 1998, the mean interval was 26 to 46.7 months). There is still great variability in the delay to treatment because frequently the diagnosis is missed at the time of initial operation and the diagnosis is made much later when the patient represents with morbidity secondary to the fistula. Eleven of the reported patients had initial emergency "damage control" operations with the fistula diagnosed subsequently. Potential fistula-related complications include congestive heart failure, pulmonary hypertension, coronary steal syndrome with secondary myocardial ischemia, bacterial endocarditis, coronary artery aneurysm formation, and delayed coronary artery aneurysm rupture [1, 11]. From study of the natural history of traumatic coronary artery fistulas, the risk of morbidity from unrepaired fistulas outweighs the risk from the reparative operation, and so early intervention has been advocated [1].

Early reports showed a preponderance of cases repaired by external ligation with or without bypass to the distal occluded vessel (1960 to 1969, 75% external ligation vs 25% closure from within) [1]. However, in the decades 1970 to 1979 and 1980 to 1989, fistulas were more commonly closed definitively from within the recipient chamber, as described in our case report (1970 to 1979, 54% incidence of closure from within the recipient chamber; 1980 to 1989, 60%). Recently (1990 to 1998), there have been few reports of accidental TCAF, but those that are reported reveal that fistula closure by external ligation is the most common technique of definitive fistula repair (three of four) [27–29].

The incidence of fistula recurrence has shown a trend to decrease over this series, with a 75% incidence of fistula recurrence in the decade 1960 to 1969 and a 0% incidence in the past two decades. External ligation/obliteration was used in 14 of 25 cases of the operative cohort (56%) with a recurrence rate of four of 14 (28.6%), whereas closure from within the recipient chamber was employed in 11 of 25 cases (44%) with a lower recurrence rate of 2 of 11 (18%). Of the 6 patients (24% of operative cohort) who experienced fistula recurrence, 2 were successfully managed conservatively. Four of the recurrent fistulas were treated by repeat operation; the original operative technique was external ligation in three of four, and closure from within the recipient chamber in one of four. All patients with repaired recurrent fistulas were asymptomatic at the last time attended to (follow-up ranges from time of discharge to 2 years).

Of the six reported cases in which accidental TCAF were treated conservatively, four were asymptomatic at the time of follow-up (ranging from 2 to 20 years postinjury), one had an unspecified clinical outcome, and one was deceased secondary to congestive heart failure.

Iatrogenic traumatic coronary artery fistulas
Iatrogenic TCAF can be divided into postoperative, post-endomyocardial biopsy, and postpercutaneous transluminal coronary angioplasty (PTCA) (Tables 3–5) [36–55]. Although these are reported to be rare entities, it is likely that the true incidence is underestimated. Post-endomyocardial biopsy rates of TCAF are reported ranging from 0% to 14% [38–47, 56], and only two case reports of post-open heart operation fistulas [36, 37] and eight case reports of post-PTCA fistulas were identified on literature review [47–55]. From these reports, the vast majority were treated conservatively (approximately 63 fistulas), the patients remained asymptomatic, and frequently the fistulas spontaneously resolved angiographically. One of the larger series reports a 76% incidence of spontaneous fistula resolution, with 18% of fistulas unchanged in size at follow-up angiography with no patient complications attributed to the presence of the TCAF [46]. Five mortalities are reported in the series of iatrogenic TCAF. Two heart transplant recipients died after endomyocardial biopsy-induced TCAF, but in neither case was the TCAF felt to be responsible for the patient’s demise [38, 47]. Three patients died post-PTCA-induced TCAF; two of the deaths were secondary to fatal myocardial infarction (in both cases, the TCAF had been treated conservatively), and in the third, the cause of death was unknown [49, 51, 54].


   Comment
Top
 Abstract
 Introduction
 Case presentation
 Literature review
 Comment
References
 
Early intervention in coronary artery-cameral fistulas prevents the late complications of high flow left-to-right shunting, including development of pulmonary artery hypertension and congestive heart failure. Early treatment requires early diagnosis, early diagnosis in turn requires a high level of suspicion. Even when we reviewed the initial echocardiogram of our trauma patient retrospectively, there was no evidence of a fistula, as the short axis views failed to include the relevant portion of the right ventricle and right coronary artery. However, the moderate tricuspid regurgitation was an overlooked clue that should have stimulated us to consider the trajectory of the penetrating wound and the possible involvement of the coronary artery.

The operative technique associated with lowest recurrence rate is closure from within the recipient chamber, although in the past two decades, there has been no recurrence regardless of which fistula closure technique was employed. As for repair of peripheral vascular arteriovenous fistulas, outcome is directly related to clear delineation of the aberrant anatomy and precise reconstruction [57]. Closure from within the recipient chamber leaves the native circulation intact and thus avoids local myocardial ischemia secondary to coronary artery ligation or the need to bypass graft the distal coronary artery. Closure from within the recipient chamber, when this chamber is the right atria or right ventricle, can be done with a fibrillating heart, obviating the need for hypothermia or cardioplegic cardiac arrest [1]. In our case, the injury involved the anterolateral wall of the right ventricle remote to the tricuspid valve and may have been identifiable from within the fibrillating ventricle. We feel that operating on the arrested heart allows for the safest and most accurate reconstruction of the coronary artery. In our case, as in other cases with delayed diagnosis of TCAF, the coronary artery was greatly dilated (10-mm diameter) because of the high-volume fistula flow, and this dilation further protects against the possibility of compromising the caliber of the coronary artery when performing a transcoronary repair, as we did.

Proponents of the external ligation technique argue that 10 of 11 cases treated with external ligation are asymptomatic at the time of follow-up and that of two recurrent fistulas, one was treated conservatively with successful spontaneous resolution of the fistula and the other was reoperated with successful resolution of the fistula. Regardless of the mode of treatment, there were no deaths in the surgically treated cohort.

Conservative treatment has been offered to a minority of patients with accidental TCAF (6 of 33), and there was one death in this cohort (1 of 6 [17%]). From the case report detailing the single mortality in this cohort, the patient refused surgical intervention and died 2 years postinjury secondary to congestive heart failure [32]. This is an entirely preventable death, as illustrated by the absence of any mortalities in the surgically treated group.

Iatrogenic TCAF have a different clinical course than accidental TCAF, likely because the size of defect created in the wall of the coronary artery by a transluminal biopsy forcep is smaller than that created by a gunshot wound or stab injury.

Transesophageal echocardiography is an inexpensive, noninvasive and sensitive tool that should be a routine part of the initial workup in trauma patients with suspicious cardiothoracic injuries and may spare patients the morbidity of a delayed intervention [58–60].

Summary
Early operative intervention remains the recommended treatment of accidental traumatic coronary artery fistulas. Closure of the fistula from within the recipient chamber is an attractive technique because it spares the involved coronary artery and because it has been associated historically with lower recurrence rates. However, the keys to successful surgical intervention in traumatic coronary artery fistulas are a high level of suspicion and careful early intervention regardless of the technique employed.

Iatrogenic traumatic coronary artery fistulas follow a more benign clinical course and may be safely observed in the asymptomatic patient, although in the symptomatic patient they should be addressed as for any other acquired coronary artery fistula.


   References
Top
 Abstract
 Introduction
 Case presentation
 Literature review
 Comment
 References
 

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