Embolization of a complex coronary to pulmonary artery fistula using balloon assisted liquid embolic injection: A novel technique.

Complex Coronary artery to Pulmonary artery fistulas (CPFs) can be difficult to manage with embolization or ligation. An 88-year-old woman with exertional angina was found to have a complex precordial CPF, severe Mitral regurgitation, and Pulmonary Hypertension. CPF treatment was recommended prior to minimally invasive mitral valve replacement (to avoid postoperative myocardial ischemia from worsened steal). The CPF was supplied by multiple branches from the LAD and RCA, and formed a complex common varicosity with multiple drainage channels to the pulmonary artery. The CPF was treated by injecting a liquid embolic agent, Ethylene Vinyl Alcohol Copolymer (Onyx, Medtronic, MN), into two of the feeding arteries arising from the RCA through a Scepter C Dual lumen balloon micro catheter (Microvention, Aliso Viejo, CA. This resulted in complete obliteration of the fistula, and the patient subsequently underwent successful mitral valve replacement surgery.