PMC6136583_01
Left coronary angiography demonstrating severe stenosis of the left circumflex artery and CTO of the LAD.
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CTO of the left anterior descending artery (Figure 1, Supplementary Video 1). Coronary artery bypass surgery was offered to the patient but declined.
Epicardial vessel from the distal right coronary artery (white arrow) collateralizing the diagonal branch (black arrow).
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An epicardial collateral from the distal right coronary artery was used to access the diagonal branch retrograde, and this wire was steered into the antegrade guide catheter and externalized (Figure 2). At that point, the balloon suddenly expanded. Angiography revealed contrast filling of the right ventricle (RV), with the appearance of one or two focal jets of contrast extravasation at the location of the rigid lesion in the distal LAD, consistent with iatrogenic LAD-RV fistula (Figure 3, Supplementary Video 2).
Angiography of the LAD demonstrating an iatrogenic LAD to RV fistula.
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At that point, the balloon suddenly expanded. Angiography revealed contrast filling of the right ventricle (RV), with the appearance of one or two focal jets of contrast extravasation at the location of the rigid lesion in the distal LAD, consistent with iatrogenic LAD-RV fistula (Figure 3, Supplementary Video 2). LAD and diagonal branch. LAD-RV fistula appeared relatively unchanged compared to during the CTO procedure (Figure 3).
Angiography of the LAD showing successful coil embolization and complete cessation of flow into the RV.
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Angiogram of the LAD confirmed complete cessation of flow into the distal LAD and absence of shunt flow (Figure 4, Supplementary Video 4).