Coronary Fistula Presented with Acute Coronary Syndrome Treated by Crushing a Covered Stent

Coronary Fistula Presented with Acute Coronary Syndrome Treated by Crushing a Covered Stent | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Coronary Fistula Presented with Acute Coronary Syndrome Treated by Crushing a Covered Stent Vedat ASLAN, Sefa SURAL This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6636405/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Jul, 2025 Read the published version in BMC Cardiovascular Disorders → Version 1 posted 10 You are reading this latest preprint version Abstract Background Coronary artery fistulas (CAFs) are abnormal vascular connections that allow blood to drain another vessel or heart chamber, potentially leading to angina and heart failure. While often found incidentally, medium-sized and large CAFs necessitate closure to prevent hemodynamic complications. Case Presentation: A 72-year-old woman was admitted to the emergency department with chest pain and was diagnosed with non-ST elevation myocardial infarction (MI). Coronary angiography revealed severe coronary stenosis and a large fistula. The large fistula was successfully treated by crushing a covered stent. This method treats the coronary fistula as a side branch while identifying the originating vessel as the main vessel. A covered stent is inserted into the coronary fistula, extending to the main vessel. The protruding segment is subsequently crushed via an open-cell drug-eluting stent parked within the main vessel. Conclusion This case highlights a different technique for managing large coronary fistulas among nonsurgical options. The use of drug-eluting stents to crush a covered stent effectively manages coronary fistulas, offering an alternative to traditional surgical or percutaneous methods. Acute coronary syndrome coronary vessel anomaly coronary artery fistula covered stent crush technique interventional cardiology Figures Figure 1 Figure 2 Figure 3 Figure 4 BACKGROUND Coronary artery fistulas (CAFs) are vascular pathways characterized by the drainage of blood into another vessel or cardiac chamber [1]. They are often discovered incidentally during cardiac imaging and affect approximately 0.1–0.2% of the population [2,3]. CAFs are classified as small, medium, or large, with medium and large CAFs potentially contributing to conditions such as angina and heart failure, depending on their diameter [4]. Small fistulas tend to close spontaneously, whereas medium and large fistulas typically require surgical or percutaneous intervention for closure [5,6]. Closure techniques include coil embolization, vascular occluders, and covered stents; however, these methods may carry risks of serious complications [2]. In this report, we present an alternative method for managing a large coronary fistula associated with severe coronary stenosis, utilizing a technique familiar to interventional cardiologists. CASE PRESENTATION A 72-year-old woman was admitted to the emergency department with a complaint of retrosternal burning chest pain occurring at rest, which had a squeezing nature, did not radiate, lasted for 10--15 minutes, and resolved spontaneously. The electrocardiogram indicated a normal sinus rhythm with minimal ST-T segment changes [Figure 1]. Upon admission to the hospital, her vital signs were normal: her heart rate was 75 beats per minute, and her blood pressure was 126/72 mmHg. Cardiac auscultation findings were normal, with no murmur detected. The patient had a history of smoking and chronic obstructive pulmonary disease but lacked a history of diabetes, hypertension, or other comorbidities. The patient's troponin level was 0.598 µg/L (reference range: 0–0.16), leading to her admission to the coronary intensive care unit with a diagnosis of non-ST elevation myocardial infarction (MI). In addition to cardiac enzymes, other laboratory tests did not reveal significant pathology. The baseline haemoglobin level was 11.1 g/dl, the serum creatinine level was 0.49 mg/dl, and the eGFR was >90 mL/min/1.73 m². The chest X-ray was evaluated as usual. Two-dimensional transthoracic echocardiography revealed a left ventricular (LV) ejection fraction of 45%, with the anterior, middle, and apical regions of the LV exhibiting hypokinesia; significant valvular disease was not identified. Coronary angiography (CAG) was conducted after 12 hours of anti-ischemic treatment, revealing a high-flow coronary artery fistula (CAF) draining from the proximal part of the left anterior descending artery (LAD) into the main pulmonary artery (MPA), along with critical stenosis in the middle of the LAD [Figure 2]. The procedure was halted for evaluation by the heart team. The heart team decided to perform coronary artery bypass grafting and resect the fistula; however, owing to comorbidities and the patient's preference, the team chose to pursue transcatheter closure (TCC). We primarily diagnose CAFs via CAG; however, computed tomography (CT) coronary angiography is the gold standard because of its superior 3D anatomical visualization [7-9]. The CAF diagnosis was clear in this case, and the drainage location was nearly certain [Figure 2A]. The fistula from the LAD drained into the MPA [Figure 2A]; therefore, we did not need to perform further examinations such as CT angiography or right heart catheterization on the patient. Similar to the crush technique [10] (bifurcation technique), the goal was to advance a covered stent (CS) into the fistula, treating it as a side branch and crushing the protruding segment with an open-cell drug-eluting stent (DES) in the main branch while sealing the ostium of the side branch (the fistula). This method aims to minimize contact between the covered stent and the main vessel. The decision was made to use the PK Papyrus CS (Biotronik, Lake Oswego, Oregon) because of its more flexible structure. Before the procedure, the patient received dual antiplatelet therapy (clopidogrel and acetylsalicylic acid), and the procedure commenced. First, two separate 0.014 guidewires were introduced into the LAD artery and the fistula. Appropriate predilation was performed for stent placement in the middle region of the LAD stenosis. A 3.5 mm × 22 mm Resolute Integrity (Medtronic Inc., Minneapolis, U.S.A.) drug-eluting stent (DES) was subsequently implanted. The large fistula was then treated by crushing a CS, as shown in Figure 3 and presented in Video 1. The flow through the fistula was completely blocked, and the LAD artery had no residual stenosis (Figure 4, Video 1). The procedure was terminated. The method we introduced in this case was performed in the following order after the critical lesion in the LAD was stented [Figure 3]: Parking a CS in the side branch (fistula) —> parking the stent in the LAD —> deploying the CS —> removing the wire and balloon from the fistula —> deploying the stent in the LAD along with crushing the stent in the fistula —> postdilating the crushed part of the CS with a larger, more suitable diameter balloon in the main vessel-> terminating the procedure. After two days of follow-up, the patient's symptoms improved, and she was discharged. The patient remained asymptomatic during regular check-ups. Follow-up at the 18th month indicated that the patient had no limiting symptoms. DISCUSSION Coronary artery fistulas (CAFs) are frequently diagnosed incidentally during coronary angiography (CAG) or other cardiac imaging [2]. In our case, a CAF was identified during CAG as part of an evaluation for acute coronary syndrome (ACS). Depending on the size and location of CAFs, the myocardial steal phenomenon can lead to shortness of breath, angina, and heart failure; however, most patients remain asymptomatic [3]. The initial presentation in our patient included chest pain, and troponin positivity was detected; however, it remains unclear whether the lesion responsible for ACS was due to an unstable coronary plaque or the steal phenomenon associated with the fistula. The critical stenosis in the midsection of the LAD may have increased blood flow through this fistula and contributed to the steal phenomenon as well. ACS may represent a syndrome in which both the fistula and coronary stenosis play a role in this patient's condition. Coronary artery fistulas are classified as small, medium, or large, corresponding to measurements of 1, 1–2, or 2 times the diameter of the largest coronary artery from which they do not originate [2]. In this case, a large segment of the aneurysm with irregular edges resembling a magician's hat was observed, following the smooth course of the fistula [Figure 2 B]. Thus, it was decided to close the fistula while treating critical LAD stenosis. The optimal timing and role of CAF intervention have not been clearly defined. Therefore, the management of these patients should be determined by a heart team that includes an experienced interventional cardiologist, a pediatric cardiologist, and an experienced cardiothoracic surgeon [2]. Our case was evaluated by the heart team, and bypass therapy was prioritized for treating both the fistula and the long coronary stenosis in the LAD. However, a decision was made to proceed with transcatheter intervention due to comorbidities (COPD, obesity). Fistula closure methods, other than surgical techniques, include coil embolizers, vascular occluders, and graft stents [2]. In this case, vascular occluders and embolizing coils were not preferred because of the risk of device embolization and the migration of pushable coils [2], given that the fistula originated from a significant vessel. The fistula opened into the pulmonary artery, and the migration of pushable coils into the pulmonary artery could have caused a pulmonary embolism and created another serious clinical situation. Covered stents are alternative tools used to treat CAFs and are implanted through coaxial insertion into the originating vessel to close the ostium of the fistula. However, covered stents carry a 10–15% risk of thrombosis and a 30% risk of in-stent restenosis within the first six months postimplantation; therefore, their routine use in CAFs is not advisable [2,11]. Furthermore, covered stents can cause significant side branch flow loss. In this case, the conventional use of a CS would have obstructed the flow of a diagonal artery and a septal artery located very close to the fistula. The approach we propose minimizes side branch loss and reduces the contact of the CS with the main vessel. In our case, the protruding portion of the CS was lengthy. In future cases, keeping the protruding and crushed segment of the CS shorter could further diminish the risk of thrombosis and restenosis. Treating fistulas by crushing covered stents may represent a novel method. This technique may be especially suitable for interventional cardiologists familiar with bifurcation techniques. Several points must be considered when the technique is applied. First, the guidewire in the fistula should be pulled immediately after placing the CS and must not be forgotten in the fistula. This oversight may cause the wire to become trapped and jailed while the CS is crushed. Second, hemodynamic instability may arise due to sudden and temporary complete occlusion of the distal flow in the main vessel immediately after the CS is placed in the fistula extending toward the main vessel. To prevent this, the CS should be crushed immediately by the previously parked stent in the main vessel right after the guidewire in the fistula is withdrawn. We did not encounter any haemodynamic instability at this stage. Intravascular ultrasonography (IVUS)-guided stenting is known to improve long-term outcomes [12]. However, due to supply issues, IVUS could not be utilized in this case. This technique may yield optimal results when performed with IVUS. Recanalization is a significant concern for CAF patients who have undergone both surgical and percutaneous closure. Follow-up imaging with CT angiogram or invasive CAG is recommended within 1 to 5 years after closure or for patients experiencing recurrent symptoms [2]. Additionally, it remains unclear how long antiplatelet therapy should be continued for these patients. Our patient was asymptomatic at the 18th month of her follow-up and during her assessments. We did not consider performing control CAG during the early period when she was asymptomatic. We acknowledge that our patient belonged to the high-risk group and decided to continue initiating dual antiplatelet therapy before closure without interruption. CONCLUSION Effective percutaneous closure techniques provide nonsurgical options for medium–to-large CAFs. The use of drug-eluting stents to crush a covered stent effectively treats coronary fistulas represents an alternative to traditional methods. Further research is essential to identify suitable treatment options and evaluate medium- and long-term outcomes. Abbreviations CAFs : coronary artery fistulas CAG: Coronary angiography COPD: Chronic obstructive pulmonary disease CS: Covered Stent CT : Computed tomography DES: Drug-Eluting Stent LAD: left anterior descending MPA: main pulmonary artery TCC: Transcatheter closure Declarations Statement of Ethics All procedures were conducted in accordance with ethical standards, particularly the Declaration of Helsinki. The patient provided informed consent to publish the images in this case report. In accordance with local and national guidelines, ethical approval was not required for this study. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Conflict of interest statement The authors acknowledge that they have no known competing financial interests or personal relationships that could be perceived to influence the work reported in this paper. Funding statement This research did not receive funding from any specific agency in the public, commercial, or not-for-profit sectors. Authors' contributions Vedat Aslan was the primary physician responsible for the case. He underwent initial treatment and angiography and then presented the case to the heart team. Following the heart team’s decision, he carried out the procedure. Sefa Sural conceived the idea for this alternative technique and created a case-specific “Figure 3” in digital format. Both authors prepared, reviewed, and approved the manuscript. Acknowledgement I would like to thank the patient and all the doctors who supported this case report. Consent to Publish declaration Written informed consent for publication of this case report and accompanying images was obtained from the patient. Clinical trial number Not applicable. References Vaidya YP, Green GR. Coronary artery fistula. J Card Surg. 2019 Dec;34(12):1608-1616. doi: 10.1111/jocs.14267. Epub 2019 Sep 26. PMID: 31557360. Al-Hijji M, El Sabbagh A, El Hajj S, et al. Coronary Artery Fistulas, Indications, Techniques, Outcomes, and Complications of Transcatheter Fistula Closure. https://doi.org/10.1016/j.jcin.2021.02.044 Kumar R, Kumar J, O'Connor C, et al. Coronary Artery Fistula: A Diagnostic Dilemma. Interv Cardiol. 2023 Nov 23;18:e25. doi: 10.15420/icr.2022.34. PMID: 38125927; PMCID: PMC10731518.4. Qureshi SA, Tynan M. Catheter closure of coronary artery fistulas. J Interv Cardiol. 2001 Jun;14(3):299-307. doi: 10.1111/j.1540-8183.2001.tb00336.x. PMID: 12053388 Qureshi SA, Tynan M. Catheter closure of coronary artery fistulas. J Interv Cardiol. 2001 Jun;14(3):299-307. doi: 10.1111/j.1540-8183.2001.tb00336.x. PMID: 12053388. Sunder KR, Balakrishnan KG, Tharakan JA, et al. Coronary artery fistula in children and adults: a review of 25 cases with long-term observations. Int J Cardiol. 1997 Jan 3;58(1):47-53. doi: 10.1016/s0167-5273(96)02792-1. PMID: 9021427. Davis JT, Allen HD, Wheller JJ, Chan DP, Cohen DM, Teske DW, Cassidy SC, Craenen JM, Kilman JW. Coronary artery fistula in the pediatric age group: a 19-year institutional experience. Ann Thorac Surg. 1994 Sep;58(3):760-3. doi: 10.1016/0003-4975(94)90743-9. PMID: 7944700. Vitarelli A, De Curtis G, Conde Y, et al. Assessment of congenital coronary artery fistulas by transesophageal color doppler echocardiography. Am J Med 2002;113:127–33. https://doi.org/10.1016/s0002-9343(02)01157-9; PMID: 12133751. Krishnamoorthy KM, Rao S. Transesophageal echocardiography for the diagnosis of coronary arteriovenous fistula. Int J Cardiol 2004;96:281–3. https://doi. org/10.1016/j.ijcard.2003.03.031; PMID: 15262046. Erdem K, Ozbay Y. Prevalence and characteristics of coronary artery anomalies using invasive coronary angiography in 6237 consecutive patients in a single center in Turkey. Arch Iran Med 2018;21:240–5. PMID: 29940742. Moroni F, Yeh JSM, Attallah A, et al. Crush techniques for percutaneous coronary intervention of bifurcation lesions. EuroIntervention. 2022 May 15;18(1):71–82. doi: 10.4244/EIJ-D-21-00690 Lee WC, Hsueh SK, Fang CY, Wu CJ, Hang CL, Fang HY. Clinical Outcomes Following Covered Stent for the Treatment of Coronary Artery Perforation. J Interv Cardiol. 2016 Dec;29(6):569-575. doi: 10.1111/joic.12347. Epub 2016 Oct 25. PMID: 27781308. Zhang J, Gao X, Kan J, et al. Intravascular Ultrasound Versus Angiography-Guided Drug-Eluting Stent Implantation: The ULTIMATE Trial. J Am Coll Cardiol. 2018 Dec 18;72(24):3126-3137. doi: 10.1016/j.jacc.2018.09.013. Epub 2018 Sep 24. PMID: 30261237. Additional Declarations No competing interests reported. Supplementary Files Video1.mp4 Cite Share Download PDF Status: Published Journal Publication published 28 Jul, 2025 Read the published version in BMC Cardiovascular Disorders → Version 1 posted Editorial decision: Revision requested 02 Jun, 2025 Reviews received at journal 01 Jun, 2025 Reviewers agreed at journal 01 Jun, 2025 Reviews received at journal 31 May, 2025 Reviewers agreed at journal 30 May, 2025 Reviewers invited by journal 29 May, 2025 Editor invited by journal 20 May, 2025 Editor assigned by journal 17 May, 2025 Submission checks completed at journal 17 May, 2025 First submitted to journal 10 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6636405","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":463488370,"identity":"b8ab5bc8-93b4-4caa-bcfb-a71f1bcfd9e2","order_by":0,"name":"Vedat ASLAN","email":"","orcid":"","institution":"Toros University","correspondingAuthor":false,"prefix":"","firstName":"Vedat","middleName":"","lastName":"ASLAN","suffix":""},{"id":463488371,"identity":"35be6adc-47c0-4bd0-8e28-aa73e3e1e4c6","order_by":1,"name":"Sefa SURAL","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYDCCA0BcAWYxNz6AcInRcgbMYmw2IFlLmwRRWvhuH3/44EBNXeL29oNt1Tw1d+T4GZgfPrqBR4vkuRxjgwPHDifOOZPYdpvn2DNjyQY2Y+McPFoMzvCwSX9gO5A4gwGkhe1w4oYDQBH8Wtif/zjwry5xBv/DtmKef0RpYTBjONjGnDhDIrGNmbeNCC2SZ3iMJQ72HTaeIfGwWXIukCHZTMAvfGfYH3448K1OdgZ/8sEPb74dluNnb374GJ8WFMDEAyKZiVUOAow/SFE9CkbBKBgFIwYAAFgRVcd0xYJgAAAAAElFTkSuQmCC","orcid":"","institution":"Toros University","correspondingAuthor":true,"prefix":"","firstName":"Sefa","middleName":"","lastName":"SURAL","suffix":""}],"badges":[],"createdAt":"2025-05-10 18:53:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6636405/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6636405/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12872-025-05059-y","type":"published","date":"2025-07-28T16:20:58+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83813173,"identity":"0f8447aa-09fc-4aa4-ad22-7a673a9a1f7d","added_by":"auto","created_at":"2025-06-03 07:19:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":518521,"visible":true,"origin":"","legend":"\u003cp\u003eA 12-lead electrocardiogram (ECG) was obtained at the time of the patient’s initial presentation at the hospital.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6636405/v1/d5597ac70b9856568f471948.png"},{"id":83814387,"identity":"ab2522f6-4b54-496b-833d-2ba989029a41","added_by":"auto","created_at":"2025-06-03 07:27:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":341325,"visible":true,"origin":"","legend":"\u003cp\u003eAngiographic visualization of the coronary fistula and aneurysmal segment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA. \u003c/strong\u003eCoronary angiography revealed a fistula that originated from the left anterior descending artery (LAD) and drained into the main pulmonary artery (MPA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB. \u003c/strong\u003eAsterisks indicate a significantly dilated aneurysmal segment, morphologically resembling a magician’s hat.\u003cbr\u003e\n(LAD = left anterior descending artery; MPA = main pulmonary artery)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6636405/v1/4e9f0b502229bd168f8fd497.png"},{"id":83814388,"identity":"ff31b72e-a1b1-484b-ae9a-e90ef88055ce","added_by":"auto","created_at":"2025-06-03 07:27:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":337988,"visible":true,"origin":"","legend":"\u003cp\u003eStepwise illustration of the procedure.\u003c/p\u003e\n\u003cp\u003e(\u003cstrong\u003eA\u003c/strong\u003e) A 4.0 mm × 20 mm PK Papyrus covered stent (CS) was advanced into the coronary fistula, whereas a 4.0 mm × 22 mm drug-eluting stent (DES, Resolute Integrity) was positioned in the left anterior descending artery (LAD).\u003cbr\u003e\n(\u003cstrong\u003eB\u003c/strong\u003e) The CS was deployed with a 4–5 mm protrusion into the LAD, and the guidewire inside the fistula was withdrawn.\u003cbr\u003e\n(\u003cstrong\u003eC\u003c/strong\u003e) The DES was implanted in the LAD to crush the protruding portion of the CS.\u003cbr\u003e\n(\u003cstrong\u003eD\u003c/strong\u003e) The crushed segment was postdilated via a 4.5 mm × 12 mm noncompliant (NC) balloon.\u003cbr\u003e\n(\u003cstrong\u003eE\u003c/strong\u003e) Final angiography confirmed complete occlusion of the fistula and successful sealing of the CS ostium.\u003cbr\u003e\n(CS = covered stent; DES = drug-eluting stent; LAD = left anterior descending artery; NC = noncompliant balloon)\u003c/p\u003e\n\u003cp\u003eThe flow through the fistula was completely blocked, and the LAD artery had no residual stenosis [Figure 4]. The procedure was terminated.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6636405/v1/7d9b05eefd5aa7a790607c1a.png"},{"id":83813176,"identity":"bacf102b-30f1-405f-8f15-359861c2787b","added_by":"auto","created_at":"2025-06-03 07:19:11","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":369047,"visible":true,"origin":"","legend":"\u003cp\u003eAngiographic confirmation of complete occlusion of fistula flow.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA:\u003c/strong\u003e RAO cranial plane; \u003cstrong\u003eB\u003c/strong\u003e: LAO cranial plane\u003cbr\u003e\n(RAO = right anterior oblique, LAO = left anterior oblique)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6636405/v1/6d77835bf6f4a315143ad8cc.png"},{"id":88268174,"identity":"75acb97d-1687-4e41-8465-4a1e1f78ff3b","added_by":"auto","created_at":"2025-08-04 16:49:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2080272,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6636405/v1/df2a28c3-5d58-415d-bb18-44768387bf99.pdf"},{"id":83813180,"identity":"2f5a0e6e-04a9-4ca0-bf4c-0cec56325929","added_by":"auto","created_at":"2025-06-03 07:19:16","extension":"mp4","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":84367406,"visible":true,"origin":"","legend":"","description":"","filename":"Video1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6636405/v1/456b95e778ab98ef58650c49.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Coronary Fistula Presented with Acute Coronary Syndrome Treated by Crushing a Covered Stent","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eCoronary artery fistulas (CAFs) are vascular pathways characterized by the drainage of blood into another vessel or cardiac chamber [1]. They are often discovered incidentally during cardiac imaging and affect approximately 0.1\u0026ndash;0.2% of the population [2,3]. CAFs are classified as small, medium, or large, with medium and large CAFs potentially contributing to conditions such as angina and heart failure, depending on their diameter [4]. Small fistulas tend to close spontaneously, whereas medium and large fistulas typically require surgical or percutaneous intervention for closure [5,6]. Closure techniques include coil embolization, vascular occluders, and covered stents; however, these methods may carry risks of serious complications [2]. In this report, we present an alternative method for managing a large coronary fistula associated with severe coronary stenosis, utilizing a technique familiar to interventional cardiologists.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA 72-year-old woman was admitted to the emergency department with a complaint of retrosternal burning chest pain occurring at rest, which had a squeezing nature, did not radiate, lasted for 10--15 minutes, and resolved spontaneously. The electrocardiogram indicated a normal sinus rhythm with minimal ST-T segment changes [Figure 1].\u003c/p\u003e\n\u003cp\u003eUpon admission to the hospital, her vital signs were normal: her heart rate was 75 beats per minute, and her blood pressure was 126/72 mmHg. Cardiac auscultation findings were normal, with no murmur detected. The patient had a history of smoking and chronic obstructive pulmonary disease but lacked a history of diabetes, hypertension, or other comorbidities. The patient\u0026apos;s troponin level was 0.598 \u0026micro;g/L (reference range: 0\u0026ndash;0.16), leading to her admission to the coronary intensive care unit with a diagnosis of non-ST elevation myocardial infarction (MI). In addition to cardiac enzymes, other laboratory tests did not reveal significant pathology. The baseline haemoglobin level was 11.1 g/dl, the serum creatinine level was 0.49 mg/dl, and the eGFR was \u0026gt;90 mL/min/1.73 m\u0026sup2;. The chest X-ray was evaluated as usual. Two-dimensional transthoracic echocardiography revealed a left ventricular (LV) ejection fraction of 45%, with the anterior, middle, and apical regions of the LV exhibiting hypokinesia; significant valvular disease was not identified. Coronary angiography (CAG) was conducted after 12 hours of anti-ischemic treatment, revealing a high-flow coronary artery fistula (CAF) draining from the proximal part of the left anterior descending artery (LAD) into the main pulmonary artery (MPA), along with critical stenosis in the middle of the LAD [Figure 2]. The procedure was halted for evaluation by the heart team. The heart team decided to perform coronary artery bypass grafting and resect the fistula; however, owing to comorbidities and the patient\u0026apos;s preference, the team chose to pursue transcatheter closure (TCC).\u003c/p\u003e\n\u003cp\u003eWe primarily diagnose CAFs via CAG; however, computed tomography (CT) coronary angiography is the gold standard because of its superior 3D anatomical visualization [7-9]. The CAF diagnosis was clear in this case, and the drainage location was nearly certain [Figure 2A]. The fistula from the LAD drained into the MPA [Figure 2A]; therefore, we did not need to perform further examinations such as CT angiography or right heart catheterization on the patient.\u003c/p\u003e\n\u003cp\u003eSimilar to the crush technique [10] (bifurcation technique), the goal was to advance a covered stent (CS) into the fistula, treating it as a side branch and crushing the protruding segment with an open-cell drug-eluting stent (DES) in the main branch while sealing the ostium of the side branch (the fistula). This method aims to minimize contact between the covered stent and the main vessel. The decision was made to use the PK Papyrus CS (Biotronik, Lake Oswego, Oregon) because of its more flexible structure. Before the procedure, the patient received dual antiplatelet therapy (clopidogrel and acetylsalicylic acid), and the procedure commenced. First, two separate 0.014 guidewires were introduced into the LAD artery and the fistula. Appropriate predilation was performed for stent placement in the middle region of the LAD stenosis. A 3.5 mm \u0026times; 22 mm Resolute Integrity (Medtronic Inc., Minneapolis, U.S.A.) drug-eluting stent (DES) was subsequently implanted. The large fistula was then treated by crushing a CS, as shown in Figure 3 and presented in Video 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe flow through the fistula was completely blocked, and the LAD artery had no residual stenosis (Figure 4, Video 1). The procedure was terminated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe method we introduced in this case was performed in the following order after the critical lesion in the LAD was stented [Figure 3]:\u003c/p\u003e\n\u003cp\u003eParking a CS in the side branch (fistula) \u0026mdash;\u0026gt; parking the stent in the LAD \u0026mdash;\u0026gt; deploying the CS \u0026mdash;\u0026gt; removing the wire and balloon from the fistula \u0026mdash;\u0026gt; deploying the stent in the LAD along with crushing the stent in the fistula \u0026mdash;\u0026gt; postdilating the crushed part of the CS with a larger, more suitable diameter balloon in the main vessel-\u0026gt; terminating the procedure.\u003c/p\u003e\n\u003cp\u003eAfter two days of follow-up, the patient\u0026apos;s symptoms improved, and she was discharged. The patient remained asymptomatic during regular check-ups. Follow-up at the 18th month indicated that the patient had no limiting symptoms.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eCoronary artery fistulas (CAFs) are frequently diagnosed incidentally during coronary angiography (CAG) or other cardiac imaging [2]. In our case, a CAF was identified during CAG as part of an evaluation for acute coronary syndrome (ACS). Depending on the size and location of CAFs, the myocardial steal phenomenon can lead to shortness of breath, angina, and heart failure; however, most patients remain asymptomatic [3]. The initial presentation in our patient included chest pain, and troponin positivity was detected; however, it remains unclear whether the lesion responsible for ACS was due to an unstable coronary plaque or the steal phenomenon associated with the fistula. The critical stenosis in the midsection of the LAD may have increased blood flow through this fistula and contributed to the steal phenomenon as well. ACS may represent a syndrome in which both the fistula and coronary stenosis play a role in this patient's condition. Coronary artery fistulas are classified as small, medium, or large, corresponding to measurements of 1, 1\u0026ndash;2, or 2 times the diameter of the largest coronary artery from which they do not originate [2]. In this case, a large segment of the aneurysm with irregular edges resembling a magician's hat was observed, following the smooth course of the fistula [Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB]. Thus, it was decided to close the fistula while treating critical LAD stenosis.\u003c/p\u003e \u003cp\u003eThe optimal timing and role of CAF intervention have not been clearly defined. Therefore, the management of these patients should be determined by a heart team that includes an experienced interventional cardiologist, a pediatric cardiologist, and an experienced cardiothoracic surgeon [2]. Our case was evaluated by the heart team, and bypass therapy was prioritized for treating both the fistula and the long coronary stenosis in the LAD. However, a decision was made to proceed with transcatheter intervention due to comorbidities (COPD, obesity). Fistula closure methods, other than surgical techniques, include coil embolizers, vascular occluders, and graft stents [2]. In this case, vascular occluders and embolizing coils were not preferred because of the risk of device embolization and the migration of pushable coils [2], given that the fistula originated from a significant vessel. The fistula opened into the pulmonary artery, and the migration of pushable coils into the pulmonary artery could have caused a pulmonary embolism and created another serious clinical situation. Covered stents are alternative tools used to treat CAFs and are implanted through coaxial insertion into the originating vessel to close the ostium of the fistula. However, covered stents carry a 10\u0026ndash;15% risk of thrombosis and a 30% risk of in-stent restenosis within the first six months postimplantation; therefore, their routine use in CAFs is not advisable [2,11].\u003c/p\u003e \u003cp\u003eFurthermore, covered stents can cause significant side branch flow loss. In this case, the conventional use of a CS would have obstructed the flow of a diagonal artery and a septal artery located very close to the fistula. The approach we propose minimizes side branch loss and reduces the contact of the CS with the main vessel. In our case, the protruding portion of the CS was lengthy. In future cases, keeping the protruding and crushed segment of the CS shorter could further diminish the risk of thrombosis and restenosis. Treating fistulas by crushing covered stents may represent a novel method.\u003c/p\u003e \u003cp\u003eThis technique may be especially suitable for interventional cardiologists familiar with bifurcation techniques. Several points must be considered when the technique is applied. First, the guidewire in the fistula should be pulled immediately after placing the CS and must not be forgotten in the fistula. This oversight may cause the wire to become trapped and jailed while the CS is crushed. Second, hemodynamic instability may arise due to sudden and temporary complete occlusion of the distal flow in the main vessel immediately after the CS is placed in the fistula extending toward the main vessel. To prevent this, the CS should be crushed immediately by the previously parked stent in the main vessel right after the guidewire in the fistula is withdrawn. We did not encounter any haemodynamic instability at this stage.\u003c/p\u003e \u003cp\u003eIntravascular ultrasonography (IVUS)-guided stenting is known to improve long-term outcomes [12]. However, due to supply issues, IVUS could not be utilized in this case. This technique may yield optimal results when performed with IVUS.\u003c/p\u003e \u003cp\u003eRecanalization is a significant concern for CAF patients who have undergone both surgical and percutaneous closure. Follow-up imaging with CT angiogram or invasive CAG is recommended within 1 to 5 years after closure or for patients experiencing recurrent symptoms [2]. Additionally, it remains unclear how long antiplatelet therapy should be continued for these patients. Our patient was asymptomatic at the 18th month of her follow-up and during her assessments. We did not consider performing control CAG during the early period when she was asymptomatic. We acknowledge that our patient belonged to the high-risk group and decided to continue initiating dual antiplatelet therapy before closure without interruption.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eEffective percutaneous closure techniques provide nonsurgical options for medium\u0026ndash;to-large CAFs. The use of drug-eluting stents to crush a covered stent effectively treats coronary fistulas represents an alternative to traditional methods. Further research is essential to identify suitable treatment options and evaluate medium- and long-term outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCAFs\u003c/strong\u003e: coronary artery fistulas\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCAG:\u0026nbsp;\u003c/strong\u003eCoronary angiography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOPD:\u003c/strong\u003e Chronic obstructive pulmonary disease\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCS:\u003c/strong\u003e Covered Stent\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCT\u003c/strong\u003e: Computed tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDES:\u003c/strong\u003e Drug-Eluting Stent\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLAD:\u003c/strong\u003e left anterior descending\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMPA:\u003c/strong\u003e main pulmonary artery\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTCC:\u003c/strong\u003e Transcatheter closure\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatement of Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures were conducted in accordance with ethical standards, particularly the Declaration of Helsinki. The patient provided informed consent to publish the images in this case report. In accordance with local and national guidelines, ethical approval was not required for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge that they have no known competing financial interests or personal relationships that could be perceived to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive funding from any specific agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVedat Aslan was the primary physician responsible for the case. He underwent initial treatment and angiography and then presented the case to the heart team. Following the heart team’s decision, he carried out the procedure. Sefa Sural conceived the idea for this alternative technique and created a case-specific “Figure 3” in digital format. Both authors prepared, reviewed, and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI would like to thank the patient and all the doctors who supported this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of this case report and accompanying images was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVaidya YP, Green GR. Coronary artery fistula. J Card Surg. 2019 Dec;34(12):1608-1616. doi: 10.1111/jocs.14267. Epub 2019 Sep 26. PMID: 31557360.\u003c/li\u003e\n\u003cli\u003eAl-Hijji M, El Sabbagh A, El Hajj S, et al. Coronary Artery Fistulas, Indications, Techniques, Outcomes, and Complications of Transcatheter Fistula Closure. https://doi.org/10.1016/j.jcin.2021.02.044\u003c/li\u003e\n\u003cli\u003eKumar R, Kumar J, O\u0026apos;Connor C, et al. Coronary Artery Fistula: A Diagnostic Dilemma. Interv Cardiol. 2023 Nov 23;18:e25. doi: 10.15420/icr.2022.34. PMID: 38125927; PMCID: PMC10731518.4. Qureshi SA, Tynan M. Catheter closure of coronary artery fistulas. J Interv Cardiol. 2001 Jun;14(3):299-307. doi: 10.1111/j.1540-8183.2001.tb00336.x. PMID: 12053388\u003c/li\u003e\n\u003cli\u003eQureshi SA, Tynan M. Catheter closure of coronary artery fistulas. J Interv Cardiol. 2001 Jun;14(3):299-307. doi: 10.1111/j.1540-8183.2001.tb00336.x. PMID: 12053388.\u003c/li\u003e\n\u003cli\u003eSunder KR, Balakrishnan KG, Tharakan JA, et al. Coronary artery fistula in children and adults: a review of 25 cases with long-term observations. Int J Cardiol. 1997 Jan 3;58(1):47-53. doi: 10.1016/s0167-5273(96)02792-1. PMID: 9021427.\u003c/li\u003e\n\u003cli\u003eDavis JT, Allen HD, Wheller JJ, Chan DP, Cohen DM, Teske DW, Cassidy SC, Craenen JM, Kilman JW. Coronary artery fistula in the pediatric age group: a 19-year institutional experience. Ann Thorac Surg. 1994 Sep;58(3):760-3. doi: 10.1016/0003-4975(94)90743-9. PMID: 7944700.\u003c/li\u003e\n\u003cli\u003eVitarelli A, De Curtis G, Conde Y, et al. Assessment of congenital coronary artery fistulas by transesophageal color doppler echocardiography. Am J Med 2002;113:127\u0026ndash;33. https://doi.org/10.1016/s0002-9343(02)01157-9; PMID: 12133751. \u003c/li\u003e\n\u003cli\u003eKrishnamoorthy KM, Rao S. Transesophageal echocardiography for the diagnosis of coronary arteriovenous fistula. Int J Cardiol 2004;96:281\u0026ndash;3. https://doi. org/10.1016/j.ijcard.2003.03.031; PMID: 15262046.\u003c/li\u003e\n\u003cli\u003eErdem K, Ozbay Y. Prevalence and characteristics of coronary artery anomalies using invasive coronary angiography in 6237 consecutive patients in a single center in Turkey. Arch Iran Med 2018;21:240\u0026ndash;5. PMID: 29940742.\u003c/li\u003e\n\u003cli\u003eMoroni F, Yeh JSM, Attallah A, et al. Crush techniques for percutaneous coronary intervention of bifurcation lesions. EuroIntervention. 2022 May 15;18(1):71\u0026ndash;82. doi: 10.4244/EIJ-D-21-00690\u003c/li\u003e\n\u003cli\u003eLee WC, Hsueh SK, Fang CY, Wu CJ, Hang CL, Fang HY. Clinical Outcomes Following Covered Stent for the Treatment of Coronary Artery Perforation. J Interv Cardiol. 2016 Dec;29(6):569-575. doi: 10.1111/joic.12347. Epub 2016 Oct 25. PMID: 27781308.\u003c/li\u003e\n\u003cli\u003eZhang J, Gao X, Kan J, et al. Intravascular Ultrasound Versus Angiography-Guided Drug-Eluting Stent Implantation: The ULTIMATE Trial. J Am Coll Cardiol. 2018 Dec 18;72(24):3126-3137. doi: 10.1016/j.jacc.2018.09.013. Epub 2018 Sep 24. PMID: 30261237.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute coronary syndrome, coronary vessel anomaly, coronary artery fistula, covered stent, crush technique, interventional cardiology","lastPublishedDoi":"10.21203/rs.3.rs-6636405/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6636405/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCoronary artery fistulas (CAFs) are abnormal vascular connections that allow blood to drain another vessel or heart chamber, potentially leading to angina and heart failure. While often found incidentally, medium-sized and large CAFs necessitate closure to prevent hemodynamic complications.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eA 72-year-old woman was admitted to the emergency department with chest pain and was diagnosed with non-ST elevation myocardial infarction (MI). Coronary angiography revealed severe coronary stenosis and a large fistula. The large fistula was successfully treated by crushing a covered stent. This method treats the coronary fistula as a side branch while identifying the originating vessel as the main vessel. A covered stent is inserted into the coronary fistula, extending to the main vessel. The protruding segment is subsequently crushed via an open-cell drug-eluting stent parked within the main vessel.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case highlights a different technique for managing large coronary fistulas among nonsurgical options. The use of drug-eluting stents to crush a covered stent effectively manages coronary fistulas, offering an alternative to traditional surgical or percutaneous methods.\u003c/p\u003e","manuscriptTitle":"Coronary Fistula Presented with Acute Coronary Syndrome Treated by Crushing a Covered Stent","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 07:19:06","doi":"10.21203/rs.3.rs-6636405/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-02T09:57:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-01T15:25:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136143736373173304479846655509342681198","date":"2025-06-01T15:13:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-31T18:53:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54947601639621119318023576164667769588","date":"2025-05-30T16:37:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-29T07:47:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-20T12:05:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-17T14:53:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-17T14:52:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2025-05-10T18:37:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"58b9d348-00a2-4366-9feb-1d9924f1bdb6","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-04T16:40:09+00:00","versionOfRecord":{"articleIdentity":"rs-6636405","link":"https://doi.org/10.1186/s12872-025-05059-y","journal":{"identity":"bmc-cardiovascular-disorders","isVorOnly":false,"title":"BMC Cardiovascular Disorders"},"publishedOn":"2025-07-28 16:20:58","publishedOnDateReadable":"July 28th, 2025"},"versionCreatedAt":"2025-06-03 07:19:06","video":"","vorDoi":"10.1186/s12872-025-05059-y","vorDoiUrl":"https://doi.org/10.1186/s12872-025-05059-y","workflowStages":[]},"version":"v1","identity":"rs-6636405","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6636405","identity":"rs-6636405","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}