Severe Dilatation of Saphenous Vein Grafts: A Late Complication of Coronary Surgery in Which the Diagnosis Is Suggested by Chest X-Ray

Risk factors associated with saphenous vein graft aneurysm after coronary artery bypass graft

Introduction

Saphenous vein graft aneurysm (SVGA) is a rare but life-threatening complication following coronary artery bypass grafting (CABG). The authors aim to identify the potential risk factors that lead to SVGA in post-CABG patients.

Methods

A systematic review of original studies, observational studies, systematic reviews, meta-analyses, case studies, and case series was conducted using PubMed, Web of Science, Scopus, EMBASE, and Google Scholar involving adult patients (>18) with SVGA after CABG using MESH terminology in a broad search strategy. All searches were performed and analyzed according to PRISMA and duplicates were removed via Rayyan. Two independent investigators extracted and assessed the data involving demographics, and baseline data related to CABG and its manifestations.

Results

Out of 487 finalized articles, 14 of them matched the inclusion requirements and reported 12 cases of SVGAs following CABG. Atherosclerosis with intimal calcification was the most common risk factor followed by infection. Others included hyperlipidemia, pneumonia, and cardiac pathologies mostly related to the ventricles and valves.

Conclusion

Atherosclerosis associated with intimal calcification is the most common risk factor. Patient outcomes seem to improve upon early identification and regular follow-up imaging. The exclusion criteria indicated the study's limits, and future studies that address these constraints may be able to better understand the risk variables involved in the genesis of SVGA.

A Very Unusual Cause for Presyncope after Bypass: What a Surprise

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VG aneurysms can present with varied symptoms such as dyspnea, chest pain, and syncope.

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Tomographic imaging can be complementary in noninvasive assessment of SVG pathology.

Longitudinal computational fluid dynamics study of stenosis and aneurysmal degeneration of an aortorenal bypass

Saphenous vein graft (SVG) bypass placement is regarded as the optimal option for renal artery stenosis, which usually causes secondary hypertension and poor renal perfusion. Using computational fluid dynamics, this study aimed to investigate the underlying hemodynamic mechanism of the vein aneurysm and stenosis after aortorenal bypass surgery. Three-dimensional models were reconstructed based on computed tomographic angiography images of a 20-year-old female patient who suffered from uncontrollable hypertension using the image processing package Mimics (Materialise). The morphology and hemodynamic parameters in the healthy state, at initial presentation and at post-operative 9-month and 2-year follow-ups after surgery were analysed. The hemodynamic parameters became normal in the left and right renal arteries after bypass surgery. However, flow separation and stagnation occurred at the post-operative 9-month aorta-vein anastomosis, which caused asymmetrical flow and extremely high wall shear stress (WSS) and WSS gradients at the outflow vein tract, where the stenosis occurred 2 years later. In addition, the graft bending produced an asymmetrical flow pattern downstream. This research revealed that the abnormal hemodynamics, including flow separation and extremely high WSS values and gradients, caused by the retrograde flow of aortorenal bypass may be responsible for the SVG degeneration. In addition, flow asymmetry due to vessel bending is a potential risk factor for SVG aneurysm dilation.

Saphenous Vein Graft Pseudoaneurysm Repair with GraftMaster®

Saphenous vein graft (SVG) pseudoaneurysm is a rare complication of coronary artery bypass graft (CABG) surgery. Despite the high mortality associated with SVG pseudoaneurysm, there is no consensus on the optimal management of these pseudoaneurysms as they are infrequently reported in the literature. We report a case of a 55-year-old man with prior CABG surgery who presented with cough associated with hemoptysis and chest pain, and was found to have SVG pseudoaneurysm. The pseudoaneurysm was successfully closed with polytetrafluoroethylene (PTFE)-covered Jostent GraftMaster^® (Abbott Vascular, Santa Clara, CA). We propose that GraftMaster is an effective means of treating SVG pseudoaneurysms percutaneously.

Exclusion of a giant saphenous vein graft pseudo-aneurysm with a "double-layer bridging" technique

We report the case of a 72-year-old man admitted to our hospital for chest pain. He had undergone coronary artery bypass graft surgery 23 years before. Contrast-enhanced computer tomography revealed a severe double-lobed dilatation of the saphenous vein graft for the obtuse marginal branch. Coronary angiography did not opacify completely the saphenous vein graft for the huge turbulence in the dilatation. Severe saphenous vein graft dilatation have a significant mortality and it has been generally treated by surgical repair, such as resection with or without bypass of the affected territory. We described an interventional technique, named "double-layer bridging" that combines metallic DES and covered stent used in a double layer. This percutaneous technique, relatively simple and virtually usable for any type of severe dilatation independently of length, can be a reasonable and safe option to exclude giant aneurysm and maintaining distal flow.

Thrombosed aneurysm of saphenous vein coronary artery bypass grafting

We describe the case of a male patient, aged 76 years, referred for cardiac investigation due to retrosternal chest pain and dyspnea. He had a history of acute myocardial infarction and angioplasties in the last 30 years, including a saphenous vein coronary artery bypass grafting (SVCABG). Echocardiogram showed hypoechoic oval formation near the right ventricle, suggesting a pericardial cyst. Computed angiotomography revealed a predominantly fusiform and thrombosed aneurysmal dilation of the SVCABG to the right coronary artery. SVCABG aneurysms are very rare and potentially fatal. They usually appear in the late postoperative period, and patients are often asymptomatic. On radiography, it is frequently presented as enlargement of the mediastinum, with echocardiography, computed tomography and magnetic resonance imaging being very useful for diagnosis. Coronary angiography is the gold standard to detect these cases. Our report illustrates a rare situation arising late from a relatively common surgery. Due to its severity, proper recognition in the routine assessment of patients with a similar history is essential.

A case of giant saphenous vein graft aneurysm successfully treated with catheter intervention

The patient was a 67-year-old man who had undergone coronary artery bypass graft surgery using a saphenous vein graft (SVG) 22 years before. Computed tomography angiogram revealed a large aneurysm of the SVG (38 × 42 mm in diameter; 80-mm long) and total occlusion of the left anterior descending artery (LAD). We first performed percutaneous coronary intervention for chronic total occlusion of the native LAD with bi-directional approach via the SVG. One month later, we performed the trans-catheter embolization of the SVG and occluded the SVG using multiple coils. This case demonstrates that trans-catheter embolization after recanalization of native coronary artery is an effective strategy to treat an SVG aneurysm. © 2015 Wiley Periodicals, Inc.

Percutaneous closure of a coronary artery-to-vein graft anastomotic pseudoaneurysm presenting as acute coronary syndrome after recent coronary artery bypass grafting

Pseudoaneurysm formation has been reported in degenerated coronary artery saphenous vein bypass grafts, as well as in native coronary arteries after interventional procedures or blunt trauma. In contrast, pseudoaneurysm formation arising from the anastomotic site of native coronary vessels soon after coronary artery bypass grafting is rare, and neither the clinical presentation of this phenomenon nor its treatment is well described. We present the case of a 63-year-old man, a recent coronary artery bypass grafting patient, who presented with acute coronary syndrome due to a large and expanding pseudoaneurysm of the saphenous vein-to-ramus intermedius artery graft anastomosis. After several attempts, we successfully treated the pseudoaneurysm by means of percutaneous coil embolization. To our knowledge, this is the first report of acute coronary syndrome secondary to a pseudoaneurysm at the coronary artery-saphenous vein graft anastomosis. In addition, this appears to be the first report of the percutaneous treatment of such a pseudoaneurysm by means of coil embolization.

Mediastinal mass presented 36 years after coronary bypass grafting: is vein graft pseudoaneurysm a differential diagnosis?

Saphenous vein graft aneurysm is a relatively rare but serious complication of coronary artery bypass grafting (CABG). The diagnosis of such cases is clinically challenging and requires a high index of suspicion, especially if presented atypically or very late after CABG. Herein, we report a case of a saphenous vein graft pseudoaneurysm that presented 36 years after CABG and was masquerading as a right atrial myxoma on serial echocardiograms over a 2-year follow-up period.

Endovascular management of saphenous vein graft aneurysm: mutidisciplinary approach to a complex problem

Treatment of vein graft aneurysms can be achieved by redo coronary reconstructions or by transcatheter techniques. Coronary interventions infrequently use large diameter devices, that is, ≥ 6 mm, and peripheral vascular interventionalists are well versed with this size technology. We report a multidisciplinary approach with technical tips for treating this uncommon pathology using 2 peripheral polytetrafluroethylene stents using a modified guide catheter.

Giant saphenous vein graft pseudoaneurysm: treatment with a vascular occlusion device

We report the case of a 74-year old male who was evaluated for progressively enlarging right heart border on serial chest radiographs. Computed tomography of the chest revealed a pseudoaneurysm arising from the saphenous vein graft (SVG) to the posterior descending artery with mass effect on the right atrium. Coronary angiography showed severely compromised distal flow and an angiographically small territory at risk. Using a minimally invasive, catheter-based approach, an Amplatzer Vascular Plug II occlusion device was utilized successfully for embolizing the SVG pseudoaneurysm.

Differential reactivity of human mammary artery and saphenous vein to prostaglandin E(2) : implication for cardiovascular grafts

BACKGROUND AND PURPOSE

Human internal mammary arteries (IMA) and saphenous veins (SV) are frequently used for coronary artery bypass graft surgery. Intra- and postoperatively, the bypass grafts are exposed to inflammatory conditions, under which there is a striking increase in the synthesis of prostaglandin E(2) (PGE(2) ). In this context, the physiological response of these vascular grafts to PGE(2) is highly relevant. The aim of this study was thus to characterize the PGE(2) receptor subtypes (EP(1) , EP(2) , EP(3) or EP(4) ) involved in modulation of the vascular tone in these two vessels.

EXPERIMENTAL APPROACH

Rings of IMA and SV were prepared from 48 patients. The rings were mounted in organ baths for isometric recording of tension, and a pharmacological study was performed, together with associated reverse transcriptase PCR and immunohistochemistry experiments.

KEY RESULTS

PGE(2) induced contractions of IMA (E(max) = 1.43 ± 0.20 g; pEC(50) = 7.50 ± 0.10); contractions were also observed with the EP(3) receptor agonists, sulprostone, 17-phenyl-PGE(2) , misoprostol or ONO-AE-248. In contrast, PGE(2) induced relaxation of the precontracted SV (E(max) =-0.22 ± 0.02 g; pEC(50) = 7.14 ± 0.09), as did the EP(4) receptor agonist, ONO-AE1-329. These results were confirmed by the use of selective EP receptor antagonists (GW627368X, L-826266, ONO-8713, SC-51322) and by molecular biology and immunostaining.

CONCLUSIONS AND IMPLICATIONS

PGE(2) induced potent and opposite effects on the human vascular segments used for grafting, namely vasoconstriction of the IMA and vasodilatation of the SV via EP(3) and EP(4) receptors respectively. These observations suggest that EP(3) and EP(4) receptors could constitute therapeutic targets to increase vascular graft patency.

Giant saphenous vein graft pseudoaneurysm causing tricuspid valve stenosis

We present the case of a 72-year-old male who was diagnosed with a saphenous vein graft pseudoaneurysm, detected on routine chest echocardiogram 13 years after undergoing coronary artery bypass graft surgery. Intraoperative transesophageal echocardiography revealed the pseudoaneurysm to be causing functional tricuspid stenosis, which was relieved after surgical excision of the mass.

Closure of a giant saphenous vein graft aneurysm with embolization coil

Aneurysms of saphenous vein grafts (SVGs) to coronary arteries are rare, usually asymptomatic and found incidentally. We report a case of an 84-year-old female who was found to have 8.1 × 8.4 cm aneurysm of an SVG to obtuse marginal (OM) artery. The aneurysm was prior to the distal anastamosis but no flow into the OM artery was noted. Cook Tornado Embolization Coils were used successfully to occlude the SVG proximal to the aneurysm. No complications occurred. The use of embolization coils is an effective and safe method for aneurysm occlusion when the anatomy is suitable and especially when patient is high risk for repeat surgical intervention.

Percutaneous management of a long saphenous vein graft aneurysm: a case report and review of literature

Aneurysms of saphenous vein grafts are rare but can result in complications such as myocardial infarction or death. Percutaneous treatment has included a variety of approaches, including covered stents. Long aneurysms in saphenous vein grafts pose an additional challenge due to the lack of coronary covered stents with sufficient length. We present successful treatment of a long saphenous vein graft aneurysm with use of peripheral covered stents over two coronary guidewires, a 55-centimeter 8-French sheath and no guide catheter.