|Year : 2018 | Volume
| Issue : 2 | Page : 124-126
Aneurysm of the saphenous vein graft after coronary artery bypass surgery
Suman Omana Soman1, G Vijayaraghavan1, AR Muneer1, AS Ankudinov2
1 Department of Cardiology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
2 2Department of Cardiology, Irkutsk State Medical University, Irkutsk, Russia
|Date of Web Publication||6-Sep-2018|
Dr. Suman Omana Soman
Department of Cardiology, Kerala Institute of Medical Sciences, Trivandrum, Kerala
Source of Support: None, Conflict of Interest: None
Aortocoronary graft aneurysms are rare; it develops as a late complication of coronary artery bypass surgery. We report here an incidental finding of a saphenous graft aneurysm detected during routine evaluation by echocardiography and confirmed by computed tomography coronary angiography.
Keywords: Aneurysm, coronary bypass graft, Echocardiography
|How to cite this article:|
Soman SO, Vijayaraghavan G, Muneer A R, Ankudinov A S. Aneurysm of the saphenous vein graft after coronary artery bypass surgery. J Indian Acad Echocardiogr Cardiovasc Imaging 2018;2:124-6
|How to cite this URL:|
Soman SO, Vijayaraghavan G, Muneer A R, Ankudinov A S. Aneurysm of the saphenous vein graft after coronary artery bypass surgery. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2018 [cited 2018 Dec 13];2:124-6. Available from: http://www.jiaecho.org/text.asp?2018/2/2/124/240635
| Introduction|| |
Aneurysmatic transformation of coronary bypass graft is rare; it occurs many years after coronary artery bypass surgery. Aneurysm develops in venous graft, mainly due to atherosclerotic changes and systemic hypertension and also due to the injury occurring during vein-graft harvesting., Here, we report a case of aneurysm of Saphenous vein graft to posterior descending coronary artery (SVG8211;PDA), which was found incidentally during the evaluation for noncardiac surgery.
| Clinical Presentation|| |
A 67-year-old gentleman was referred to cardiology outpatient department for fitness to paraumbilical hernia repair. He had inferior wall myocardial infarction 15 years back; coronary angiogram revealed critical stenosis in the left anterior descending (LAD) coronary artery, PDA, and ramus intermedius (RI), and he underwent coronary bypass surgery with three grafts: left internal mammary artery graft to LAD coronary artery (LIMA to LAD), SVG-to-PDA, and SVG-to-RI. He was a hypertensive and dyslipidemic.
Clinically, he had no anginal symptoms or dyspnea. Clinical examination was normal. Electrocardiogram showed sinus rhythm with a heart rate of 65/min with pathological Q waves in inferior leads. Chest X-ray showed no cardiomegaly, and transthoracic echocardiogram was done for a routine preoperative cardiac evaluation.
There was dilation of the left ventricle with a diameter of 6.1/4.6 cm with the left ventricular ejection fraction of 47%; there was left atrial dilatation with 5 cm size. There was scarring noted in the basal inferior wall in view of old inferior wall myocardial infarction. Apical four-chamber view showed a cystic shadow seen near the right atrium shown in [Figure 1], which was partly cystic and partly solid. Short axis showed the cystic shadow measuring 4.7 cm × 4.8 cm in diameter shown in [Figure 2], which was round in shape. It originated near the right atrioventricular groove and projected into the right atrium. The wall of the cyst was thick and showed layered thrombus. We also noticed that there was an increase in the size of the cyst during diastole. Color flow imaging showed blood flow seen inside the cyst. We also noticed that there was blood entering into the cyst. Hence, a computed tomography (CT) coronary angiogram was done.
Multiple views of a three-dimensional surface rendered CT coronary angiography study showed native triple-vessel disease. Left main coronary artery bifurcated into LAD artery and left circumflex artery. Mid LAD was totally occluded after the first diagonal branch and distal part of LAD showed retrograde filling. LCX was totally occluded after proximal part, and the distal LCX had some retrograde flow from collaterals. Right coronary artery was totally occluded proximally after a short stump. There was a sacculo-fusiform aneurysm at the distal part of SVG-to-PDA graft as noted in [Figure 3]. The aneurysm appeared to be originating from the junction of the SVG8211;PDA graft and it continued as PDA shown in [Figure 4]. Patent LIMA graft to LAD and saphenous vein graft to ramus intermedius were also visible. The CT coronary angiogram could show only the anatomy of the aneurysm, but the echocardiogram could demonstrate the blood circulation inside the graft.
|Figure 4: Computed tomography coronary angiography showing the aneurysm and posterior descending coronary artery|
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Surgery was advised and the patient was informed about the possible complications such as infection, aneurysm rupture and sudden cardiac death. The patient deferred any surgical procedure, and hence, he was started on anticoagulation.
| Discussion|| |
Aneurysmal transformation of aortocoronary SVGs was first described by Riahi et al. in 1975 and it is a rare complication which occurs 108211;20 years after surgery  Postoperative atherosclerosis of the SVG is not rare, and Liang et al. reported that only 40%8211;45% of grafts remain normal angiographically after 10 years of coronary artery bypass surgery. Different complications of the venous grafts such as the development of fistula and compression of the pulmonary artery and graft aneurysm compression of the right atrium and ventricle have been reported.,, Here, we report a case of SVG aneurysm found incidentally during cardiac evaluation. The treatment options are surgical resection of the saphenous aneurysm, revascularization, and therapeutic embolization. The recommendation is aneurysm repair and surgical revascularization of symptomatic patients with aneurysms to prevent further complications.,, For asymptomatic patients in whom the aneurysm diameter exceeds 1 cm or in patients with diminished graft flow, surgical revascularization should be recommended. A study from Mayo clinic reported a survival rate of 83% at 5 years and 72% at 10 years after SVG aneurysm repair.
| Conclusion|| |
Aneurysmatic transformation of a venous graft after coronary bypass surgery is rare, and it leads to fatal complications. It can be diagnosed by multiple noninvasive imaging modalities. Depending on the location of the venous graft, the aneurysm can induce major complications which require surgical intervention. The primary treatment remains surgical, but transcatheter embolization is an alternative in high-risk or inoperable patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rebergen SA, Kroon HM, Buis B, Kibbelaar RE. Giant true aneurysm of an aortocoronary bypass graft: A rare cause for a mediastinal mass. Eur J Radiol 1992;15:135-7.
Mitchell MB, Campbell DN. Pulmonary artery compression by a giant aortocoronary vein graft aneurysm. Ann Thorac Surg 2000;69:948-9.
Schamroth CL, Sacks AD. Aortocoronary saphenous veinbypass aneurysm-an unusual presentation. S Afr Med J 1998;88 Suppl 2:C91-3.
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.
Sugimoto T, Yamamoto K, Yoshii S, Shimada K, Katsu M, Iida Y, et al.
Large saphenous vein graft aneurysm with a fistula to the right atrium. Ann Thorac Cardiovasc Surg 2006;12:435-7.
Liang BT, Antman EM, Taus R, Collins JJ Jr., Schoen FJ. Atherosclerotic aneurysms of aortocoronary vein grafts. Am J Cardiol 1988;61:185-8.
Ivert T, Orre L. Right thoracotomy for saphenous vein graft aneurysm causing hemoptysis. Ann Thorac Surg 2006;81:1885-7.
Williams ML, Rampersaud E, Wolfe WG. A man with saphenous vein graft aneurysms after bypass surgery. Ann Thorac Surg 2004;77:1815-7.
van de Wal RM, van Werkum JW, le Cocq d'Armandville MC, Plokker HW, Morshuis WJ. Giant aneurysm of an aortocoronary venous bypass graft compressing the right ventricle. Neth Heart J 2007;15:252-4.
Hughes MM, Rice TW, Simpfendorfer C. Aneurysmal saphenous vein graft presenting as an anterior mediastinal mass. Cathet Cardiovasc Diagn 1991;24:265-7.
Dabboussi M, Saade YA, Poncet A, Baehrel B. Fistula between a saphenous vein graft aneurysm and the pulmonary artery trunk. Ann Thorac Surg 2001;71:1356-8.
Richardson MP, Thuraisingham SI, Dunning J. Apparent obstruction of the superior vena cava and a continuous murmur: Signs of a fistula between a vein graft aneurysm and the right atrium. Br Heart J 1992;68:412-3.
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.
Sareyyupoglu B, Schaff HV, Ucar I, Sundt TM 3rd
, Dearani JA, Park SJ, et al.
Surgical treatment of saphenous vein graft aneurysms after coronary artery revascularization. Ann Thorac Surg 2009;88:1801-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]