(Circulation. 2000;102:e124.)
© 2000 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Endovascular Management of an Innominate-Caval Fistula Secondary to Insertion of a Cardiac Pacemaker
From the Departments of Vascular Surgery (A.F.L., D.R.L., J.M.) and Radiology (R.C.W.), Royal Prince Alfred Hospital, Sydney, Australia.
Correspondence to Dr Andrew F. Lennox, Vascular Laboratory, Level 9, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, Sydney, Australia, 2050. E-mail a.lennox{at}ic.ac.uk
A 69-year-old man
with ischemic heart disease presented with increasing
lethargy and breathlessness several months after coronary
artery bypass surgery. In the immediate postoperative period, he
developed heart block requiring insertion of a pacemaker; during the
procedure, however, there was excessive bleeding from the right
subclavian vein puncture site, and only a single-chamber pacemaker
could be inserted. This was upgraded to a 3-lead system via a further
right subclavian venous puncture 4 months later. One month after this
procedure, a loud continuous murmur became audible throughout the
precordium, and there was a slow deterioration of his cardiac
function. Initial echocardiography demonstrated
poor right heart compliance and a dilated inferior vena
cava, with subsequent angiography confirming the presence of an
innominate–superior vena cava fistula (Figure 1
). The defect in the innominate artery
arose from the posterolateral aspect of the vessel <1 cm from the
aortic arch origin.
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To prevent deterioration of myocardial function and in view of
the patient’s high medical risk and difficult reoperative surgical
access to the fistula, a minimally invasive endovascular technique was
used to cover the arterial defect. A retrograde approach
via surgical exposure of the right common carotid artery was used to
insert a 21F delivery device. A 20-mmx3.75-cm AneuRx
(Medtronic) covered stent (Figure 2) was
deployed across the lower innominate artery, with the proximal one
third of the graft positioned within the aortic lumen to assist in
fixation of the stent. After deployment, angiography confirmed complete
closure of the fistula (Figure 3) and
adequate flow into the left common carotid and subclavian arteries
beyond the stent. There were no postprocedural complications, and the
patient had a subsequent symptomatic improvement in cardiac
function.
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Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.
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