ABC | Volume 113, Nº5, November 2019

Case Report Calik et al. LIMA to pulmonary artery fistula Arq Bras Cardiol. 2019; 113(5):1002-1005 Figure 3 – Total occlusion of the fistula after additional coil embolization. heart failure symptoms. Continuous murmur can be heard on physical examination. Although it is very unusual, such a fistula formation can be complicated by myocardial infarction, congestive heart failure, pulmonary hypertension, arteritis, aneurysm or rupture. 6 Selective angiography of LIMA has utmost importance to diagnose this fistula formation. 10 Treatment options of LIMA-PA fistula include conservative medical therapy, surgical ligation and endovascular therapy options such as coil or vascular plug embolization and covered stent implantation. Asymptomatic patients with small fistulas and high-risk surgical patients who don’t have suitable anatomy for endovascular interventions may be followed up by conservative medical therapy; however, patients suffering from angina and congestive heart failure symptoms despite optimal medical therapy and patients having aneurysmal dilatation of fistula should be intervened either surgically or percutaneously. Currently, less invasive endovascular therapy options superseded surgical treatment which carries a significant morbidity and mortality risk. Coil and vascular plug embolization techniques are the most commonly used endovascular therapy options for treating fistula formations. However, both techniques have pros and cons. Coil embolization is generally used for smaller fistulas 11 and needs smaller catheters for delivery. Additionally, coils are low profile, easy to deliver and inexpensive devices when compared to vascular plugs. But, the Achilles' heel of coil embolization are high recanalization rates and distal embolization as we experienced in our case. On the other hand, vascular plug embolization is usually prefered for larger fistulas 11 and provides more accurate placement with less distal embolization and recanalization rates. However, vascular plugs are more expensive than coils and require larger catheters for delivery (4 French at least). Also, delivery and deployment in tortuous vessels can be challenging in some cases due to rigid catheter-release wire set. 12 Beyond the individual features of these devices, deciding the type of endovascular therapy depends on both the operator experience and anatomy of the fistula. Having said that, since our case was suffering persistent angina despite optimal medical therapy and redo operation was constituting a significant surgical risk, we decided to treat the patient with endovascular intervention. In addition, the fistula formation was suitable for transcatheter coil embolization in terms of diameter and anatomy. Since the fistula was having a tortuous structure particularly in its proximal portion, we did not use vascular plug occluder in this case. Conclusion LIMA to PA fistulas are rare conditions which can develop after bypass grafting and should be kept in mind as a cause of persistent angina. Selective angiography of the LIMAwith careful evaluation of the images are substantial for proper diagnosis and treatment of this entity. Endovascular interventions are now considered first-line therapy options. Physician and institutional experience, as well as the anatomy and characteristics of fistula, are crucial while deciding the type of endovascular therapy. Author contributions Conception anddesignof the research: CalikAN, KarabayCY, Gungor B, Kozan O; Acquisition of data: Calik AN, Karabay CY, Akdeniz E, Çanga Y, Kozan O; Writing of the manuscript: Calik AN, Akdeniz E, Çanga Y, Gungor B, Kozan O. 1004