Asian Cardiovasc Thorac Ann 2006;14:336-337
© 2006 Asia Publishing EXchange Ltd
Right Hemothorax from Leaking Aortocoronary Vein Graft Giant Aneurysm
Sushil K Singh, MCh,
Ashok K Sharma, FRACS1
Wakefield Hospital
1 Cardiothoracic Surgery, Wakefield & Wellington Public Hospital, Wellington, New Zealand
For reprint information contact: Ashok K Sharma, FRACS Tel: 64 4 381 8115 Fax: 64 4 381 8116 Email: doctorsushil{at}hotmail.com, Cardiothoracic Surgery, Wakefield Hospital, Private bag 7909, Florence Street, Newtown, Wellington South 6039, New Zealand.
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ABSTRACT
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Aneurysm of the saphenous vein aortocoronary bypass graft is a rare but potentially fatal complication of coronary artery bypass grafting (CABG). We report a case of an aneurysm of the saphenous vein aortocoronary bypass graft presented 7 years after redo CABG, with features of right atrial compression and right hemothorax. The patient was successfully treated surgically.
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INTRODUCTION
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Reversed saphenous vein grafting (RSVG) is used in the majority of cases of coronary artery bypass grafting (CABG) as aortocoronary bypass graft. Rarely does the saphenous vein graft undergo aneurysmal dilatation. There are approximately 60 cases reported in the literature, the majority being single case reports.1 Approximately two-thirds of these patients were categorized as true aneurysm and the remainder as pseudoaneurysm. An understanding of the pathophysiology of reverse aortocoronary saphenous vein bypass graft aneurysm is important to prevent the possibility of aneurysm formation, rupture, embolization, myocardial infarction, or death.
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CASE REPORT
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A 79-year-old man was admitted to the emergency department in March 2001 with a history of acute chest pain. He had been unwell for the last two years and had shortness of breath with bilateral pedal oedema. He had a history of hypertension, hypercholesterolemia and two previous cases of coronary artery bypass surgery. The first coronary artery bypass graft was performed in 1984. The redo CABG was performed in 1994, saphenous vein graft to the left anterior descending artery (the old graft was completely replaced), vein graft to the obtuse marginal (the old graft remains supplying the proximal portion), vein graft to the distal circumflex and a vein graft to the distal right coronary artery (the old graft was completely replaced).
On admission to the emergency department, a chest X-Ray examination was undertaken and revealed a large hemothorax on the right side. A computerised axial tomography scan confirmed a large hemothorax, which was displacing the mediastinum to the left. A contrast enhanced computerised axial tomography scan revealed a large mass in the mid right atrium displacing the right ventricle and the diaphragm inferiorly (Figure 1
). Unfortunately the etiopathogenesis of this large hemothorax was not very clear. A chest tube was inserted on the right side. The patient drained about 1800 mL of blood, and continued draining at a rate of 100 mL·h–1. A cardiac catheterization was performed to determine the nature of the hematoma. It was demonstrated that there was a false aneurysm of 9 cm in diameter from the right coronary graft, which appeared to be leaking into the mediastinum (Figure 2).
The operation was performed via the right 2nd intercostal space thoracotomy in which the large aneurysmal sac was identified. The saphenous vein graft was ligated with multiple pledgetted sutures proximal to the aneurysm. The right coronary artery was diffusely diseased distal to the previous anastomosis, so it was not revascularized in anticipation of a poor long-term result. A second incision was made through the 4th intercostal space and the clot was evacuated. The chest was closed after inserting an intercostal drainage tube. The patient was followed up after 3 months and he was doing well.
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DISCUSSION
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Riahi and colleagues2 first reported aneurysmal dilatation of a coronary saphenous vein graft in 1975. There have been approximately 60 published cases of saphenous vein graft aneurysms or pseudoaneurysms since then.1 The aneurysms have been of different sizes (1–13cm diameter). The mechanism of aneurysm formation remains unclear but a few causative factors have been postulated. The interval between operation and the occurrence of the aneurysm varied from 11 days to 21 years.4 True aneurysms, usually a late complication of bypass surgery are atherosclerotic in nature and appear more than five years after CABG. The early aneurysms are more likely to be false, due to infection or operative factors and occur at the anastomotic site in most of the cases.4
The majority of cases of saphenous vein graft aneurysms are asymptomatic but sometimes present as complications of coronary artery bypass graft surgery.1,3 There are only five cases of rupture of saphenous vein graft aneurysm reported in the literature.5,7
Plain chest radiography, computed tomography, transoesophageal echocardiography and magnetic resonance imaging have been used for diagnosis. Eventually, most of these patients require angiography to establish a definitive diagnosis, the extent of native coronary artery disease and possible method of treatment.1,4
Recommendations for the management of saphenous vein graft aneurysms are not well established, since the incidence is low and only individual cases have been reported. Review of the literature reveals the majority of these patients undergo surgical exclusion or resection of the aneurysm in low risk cases with or without revascularization of the native artery.1,6 Percutaneous coil embolization has been successfully used to occlude the aneurysm.4,7 A rational approach to manage patients with saphenous vein graft aneurysm has been suggested by Dieter et al.1
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CONCLUSION
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Saphenous vein graft aneurysm is a rare occurrence after CABG. In post CABG patients with hemothorax a differential diagnosis of ruptured saphenous vein graft aneurysm should always be considered.
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REFERENCES
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- Dieter RS, Patel AK, Yandow D, Pacanowski JP Jr, Bhattacharya A, et al. Conservative vs. invasive treatment of aortocoronary saphenous vein graft aneurysms: Treatment algorithm based upon a large series. Cardiovasc Surg 2003;1:507–13.
- Riahi M, Vasu CM, Tomatis LA, Schlosser RJ, Zimmerman G. Aneurysm of saphenous vein bypass graft to coronary artery. J Thorac Cardiovasc Surg 1975;70:358–9.[Abstract]
- Kallis P, Keogh BE, Davies MJ. Pseudoaneurysm of aortocoronary vein graft secondary to late venous rupture: case report and literature review. Br Heart J 1993;70:189–92.[Abstract/Free Full Text]
- Le Breton H, Pavin D, Langanay T, Roland Y, Leclercq C, et al. Aneurysms and pseudoaneurysms of saphenous vein coronary artery bypass grafts. Heart 1998;79:505–8.[Abstract/Free Full Text]
- Davey P, Gwilt D, Forfar C. Spontaneous rupture of a saphenous vein graft. Postgrad Med J 1999;75:363–4.[Abstract/Free Full Text]
- Kalimi R, Palazzo RS, Graver LM. Giant aneurysm of saphenous vein graft to coronary artery compressing the right atrium. Ann Thorac Surg 1999;68:1433–7.[Abstract/Free Full Text]
- Shapeero LG, Guthaner DF, Swerdlow CD, Wexler L. Rupture of a coronary bypass graft aneurysm: CT evaluation and coil occlusion therapy. AJR Am J Roentgenol 1983;141:1060–2.[Free Full Text]
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ABSTRACT
INTRODUCTION
