Transcatheter closure of a giant and tortuous right coronary artery-to-right atrium fistula in a child: a case report

Figures

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  Figure 1. CARE timeline summarizing the patient clinical course.

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  Figure 2. Transthoracic echocardiography demonstrating a markedly dilated right coronary artery (white asterisk) with a coronary artery fistula draining into right atrium (red arrow) in (A) Parasternal long-axis. (B) Apical four-chambers view with colour Doppler showing continuous fistulous flow into the right atrium. Selective right coronary angiography showing the angiographic anatomy of the coronary artery fistula (C) Dilatation of proximal RCA diameter measuring 5.76 mm (white arrow); (D) Giant aneurysmal sac (red arrow) arising immediately distal to dilated proximal RCA with maximal aneurysmal diameter measuring 23.54 mm (white arrow); (E) Tortuous fistulous tract beyond the aneurysm demonstrating multiple stenotic segments. The first more proximal stenotic segment, and immediately distal to the aneurysmal sac (green arrow) measuring 13.7 mm, was selected as the intended landing zone.

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  Figure 3. Failure of initial deployment resulting from suboptimal angiographic projection (A) Initial deployment of the Amplatzer® Vascular Plug II (red arrow) through the intended landing zone under the initial angiographic projection (LAO 300/CRA 300) with suboptimal device stability; (B) Device migration into right atrium following attempted deployment, indicating inadequate anchoring within fistulous tract; (C) Venous contrast injection demonstrating further migration of the unreleased device into the inferior vena cava, necessitating device recapture and subsequent redeployment.

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  Figure 4. Successful redeployment using an optimized angiographic projection and maintained arteriovenous rail. (A) Schematic illustration of the wire–sheath–device relationship. The AV guidewire was maintained within the same delivery sheath alongside the device delivery cable; (B) Redeployment of the Amplatzer® Vascular Plug II (red arrow) under the optimized angiographic projection (LAO 50°/CAU 30°) with a maintained arteriovenous rail, providing improved visualization of the intended landing zone and enhanced device stability; (C) Selective hand injection through the JR diagnostic catheter confirming appropriate device position while preserving flow to the native right coronary artery branches (white arrow) before device release; (D) Completion angiography after device release demonstrating stable device position, preserved native coronary artery flow, and complete fistula occlusion.