Asian Cardiovasc Thorac Ann 2007;15:157-158
© 2007 Asia Publishing EXchange Ltd
Off-Pump Resection of Aorto-Saphenous Vein Graft Pseudoaneurysm
Mohamad N Bittar, FRCS C-Th,
Andrew J Duncan, FRCS
Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, United Kingdom
For reprint information contact: Mohamad N Bittar, FRCS C-Th Tel/Fax: 44 161 862 9080 Email: mbittar{at}doctors.org.uk, Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, M23 9LT, United Kingdom.
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ABSTRACT
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Pseudoaneurysms of saphenous vein grafts are rare. We present the case of a 58-year-old man who presented with recurrent angina nine years following quadruple coronary artery bypass graft surgery in 1983. He was found to have an aneurysm arising from the ascending aorta. The patient underwent off-pump aorto-saphenous vein pseudoaneurysm resection and redo coronary artery bypass grafts.
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INTRODUCTION
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Saphenous vein graft (SVG) pseudoaneurysms after coronary artery bypass grafting have been reported previously in relation to anastomosis or secondary to infection. Failure to accurately diagnose this entity led to major complications including bleeding, embolization, myocardial infarction, and death. Correct preoperative diagnosis was not made in the majority of cases, with subsequent morbidity and mortality. We report the first case of an off-pump surgical technique being adopted as the method of treatment.
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CASE REPORT
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A 58-year old man with a history of deteriorating angina over three years was referred to the chest clinic in July 2002. His past medical history included quadruple coronary artery bypass grafts (CABG) in 1983 and myocardial infarction in 1985. In 1992 he was admitted to the hospital with unstable angina, and coronary angiogram revealed two blocked grafts to the circumflex artery (SVG-CX) and to the first diagonal artery. The remaining patent grafts were to the left anterior descending artery (LAD) and the right coronary artery (RCA). The ascending aorta was normal.
The patient was managed medically for nine years. Failure of medical management to control angina adequately led to further investigations. Exercise tolerance test was positive at 5 minutes standard Bruce protocol with significant lateral ST segment depression. Coronary angiography demonstrated occlusion of all grafts, severe triple coronary vessel disease, and an aneurysm arising from the ascending aorta (Figure 1
: large arrow). Magnetic resonance imaging (MRI) of the aorta showed 3.5 x 2.5 cm aneurysmal dilatation in one of the ascending aortic "cannulation" sites (Figure 2: large arrow). Surgical opinion was sought.
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Figure 1. An aortogram showing an aneurysmal dilatation of the ascending aorta (indicated by the arrow).
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At surgery, careful dissection revealed an ascending aortic aneurysm arising at the proximal anastomosis of the SVG-CX to the aorta. There was complete occlusion distal to the aneurysmal dilatation. After partial heparinization the aneurysm was carefully dissected, clamped, and resected. The aortic wall was repaired by direct closure using 4/0 Prolene sutures. The patient underwent off-pump triple coronary artery bypass graft (OPCAB) using saphenous vein grafts to the LAD, CX, and posterior descending artery branch of the RCA. Histological examination showed extensive atherosclerosis of the saphenous vein with many complicated plaques. External to its wall there was an organized and focally calcified hematoma consistent with a pseudoaneurysm.
The patient’s postoperative course was uncomplicated and he was discharged home on postoperative day 6. Six months after his operation he was free of angina and doing very well.
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DISCUSSION
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Saphenous vein graft pseudoaneurysm is a rare condition after coronary artery bypass graft, with few published cases since 1966.1,2 True aneurysms are atherosclerotic in nature and usually appear as a late postoperative complication more than 5 years after CABG.3 Pseudoaneurysms can occur early or late after surgery, and the most common location is at the anastomotic site. The exact mechanism for the development of such pseudoaneurysms is still unclear. Imperfect surgical technique with sutural defects may play a role in those cases which occur relatively early in the postoperative course. Other mechanisms are thought to include damage to the saphenous vein graft wall during initial surgery or weakness in the veins themselves at branch sites or in the region of the vein valves.2 Different presentations of SVG aneurysms have been described in the past. A mediastinal mass on plain chest X-Ray, recurrence of chest pain (which could be related to angina or myocardial infarction as a result of intraluminal thrombus formation), and hemothorax due to spontaneous rupture of the aneurysm have been described.4,5,6 Historically, diagnosis has been made incidentally at the time of surgery, however plain chest X-Ray, computed tomography, transthoracic echocardiography, transesophageal echocardiography, and magnetic resonance imaging have all been useful.
There are no well-established recommendations for treatment of saphenous vein graft aneurysms. However, it is a potentially life-threatening condition and early repair could be a life-saving procedure. Surgery (aneurysm resection and coronary revascularization) remains the primary treatment in most reported cases. However trans-catheter stenting or embolization are alternatives in high-risk cases or for inoperable patients.
In summary, saphenous vein graft pseudo or true aneurysms will be encountered more often due to the increased number of performed redo cardiac surgery. An accurate preoperative diagnosis will prevent unwelcome surprises. Off-pump surgery could be a useful technique in such cases.
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REFERENCES
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- Wyatt DA, Gay SB, Gimple LW, Spotnitz WD. Successful preoperative diagnosis and treatment of a saphenous vein coronary artery bypass graft aneurysm. Chest 1993;104:283–4.[Medline]
- Le Breton H, Pavin D, Langanay T, Roland Y, Leclercq C, Beliard JM, et al. Aneurysms and pseudoaneurysms of saphenous vein coronary artery bypass grafts. Heart 1998;79:505–8.[Abstract/Free Full Text]
- Liang BT, Antman EM, Taus R, Collins JJ Jr, Schoen FJ. Atherosclerotic aneurysms of aortocoronary vein grafts. Am J Cardiol 1988;61:185–8.[Medline]
- Taliercio CP, Smith HC, Pluth JR, Gibbons RJ. Coronary artery venous bypass graft aneurysm with symptomatic coronary artery emboli. J Am Coll Cardiol 1986;7:435–7.[Abstract]
- Lopez-Velarde P, Hallman GL, Treistman B. Aneurysm of an aortocoronary saphenous vein bypass graft presenting as an anterior mediastinal mass. Ann Thorac Surg 1988;46:349–50.[Abstract]
- Murphy JP Jr, Shabb B, Nishikawa A, Adams PR, Walker WE. Rupture of an aortocoronary saphenous vein graft aneurysm. Am J Cardiol 1986;58:555–7.[Medline]
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ABSTRACT
INTRODUCTION
