Innominate vein to left internal mammary artery bypass graft fistula during laser lead extraction: salvage with covered coronary artery stent

A 62-year-old man with a history of ventricular tachycardia and coronary artery bypass graft surgery underwent implantable cardioverter-defibrillator lead extraction with an excimer laser sheath because of a lead failure and inappropriate shocks. The procedure was complicated with an iatrogenic arteriovenous fistula between the left internal mammary artery (LIMA) and innominate vein occurred, resulting in massive bleeding into the mediastinum (Figure 1A). Since the LIMA had been employed as a coronary artery bypass graft, embolization of this vessel was not an option. A 3.0 × 19 mm covered stent (Jostent, Abbott Vascular, Abbott Park, IL, USA) was then deployed at the site of fistula (Figure 1B). As a result, the fistula was closed and perfusion of the coronary arteries was maintained (Figure 1C). An iatrogenic arteriovenous fistula between the LIMA and innominate vein can occur as a complication of lead extraction. This case demonstrates that while the likelihood of damage to the LIMA during lead extraction may be small, its consequences may be complex and require novel solutions. The use of a covered coronary artery stent in the LIMA graft effectively controlled bleeding, closed the fistula between the graft and the innominate vein, and protected patency of the graft. The full-length version of this report can be viewed at: http://www.escardio.org/communities/EHRA/publications/ep-case-reports/Documents/Innominate-vein-to-left-internal-mammary-artery.pdf