Successful management of iatrogenic coronary arteriovenous fistula developed during chronic total occlusion intervention.

There have been some reports of iatrogenic coronary arteriovenous fistula (AVF) developing during percutaneous coronary intervention (PCI). PCI for chronic total occlusion (CTO) is more challenging due to a higher rate of procedural failure and increased risk of periprocedural complications. Recently, the coronary CTO guidewire has made rapid strides and revolutionized the procedure to increase high success rates for CTO revascularization. Simultaneously, as the number of CTO interventions increases, more complicated cases have also been reported. We report a case of huge iatrogenic left circumflex artery-to-posterior vein of left ventricle fistula resulting from unexpected penetration of CTO guidewire into cardiac vein during CTO intervention, which was successfully closed by a covered stent. Although controversies still exist concerning the closure of iatrogenic AVF in asymptomatic patients, especially when it drains into a third space including cardiac chambers or venous system, we decided to perform the closure of iatrogenic AVF by covered stent due to relatively bigger AVF size which was generated immediately following balloon angioplasty.