Ann Thorac Surg 1995;60:1121-1123
© 1995 The Society of Thoracic Surgeons
Case Reports
Post-Stenting Enlarging False Aneurysm of a Saphenous Vein Graft
Takahiro Katsumata, MD,
Masahiro Endo, MD,
Kenji Ihashi, MD,
Seiji Fujino, MD,
Hiroshi Nishida, MD,
Hitoshi Koyanagi, MD
Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical College, Tokyo, Japan
Accepted for publication April 21, 1995.
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Abstract
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Stenting seems to be a definitive procedure after failed balloon coronary angioplasty. This report describes a case of redo coronary bypass grafting and concomitant resection of enlarging false aneurysm of a saphenous vein graft that developed secondary to stenting for recurrent stenosis after serial percutaneous transluminal coronary angioplasty. It warns us of a pitfall in catheter intervention in an aged saphenous vein graft.
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Introduction
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Coronary stenting has been in clinical use by most interventional cardiologists. It seems to provide confirmed revascularization even when the target vessel has a severe calcified lesion that has led to dissection or recoiling. We report a case of an enlarging false aneurysm of a saphenous vein graft (SVG) that developed secondary to stenting of a recurrent stenotic lesion after percutaneous transluminal coronary angioplasty (PTCA).
A 59-year-old man began to experience recurrent left chest pressure and shortness of breath. He had mild diabetic nephropathy and ``blue toe'' syndrome as a past history. He was referred for angiographic restudy of a previous intervention for vein graft stenosis after coronary artery bypass grafting (CABG). Eleven years earlier, he had undergone double CABG with SVGs individually to the left anterior descending artery (LAD) and to the left circumflex artery (LCX) for treatment of unstable angina after old myocardial infarction caused by occlusion of the proximal LAD and of the LCX posterolateral branch. At 8 years after CABG, anginal attack recurred. Coronary angiogram revealed a concentric lesion of 90% narrowing in the distal body of the SVG to the LAD and occlusion in the mid-right coronary artery and in a previous SVG to the LCX.
Elective PTCA to the graft stenosis was tried two times; however, it produced suboptimal release of the target because of an extensive elastic recoil that was difficult to stabilize. One month later, anginal attack still remained, and the patient underwent stenting of the recurrent graft lesion. After predilation with a 3-mm balloon catheter, a Palmaz-Schatz stent (Johnson & Johnson Interventional Systems, Warren, NJ) was successfully implanted with a 3.5-mm delivery balloon. The target lesion was released from 70% to 30% residual narrowing without major dissection or any isolated aneurysmal change.
Angiographic restudy 4 months after stenting demonstrated a fully patent graft; however, the stented segment enlarged and showed extraluminal pooling of contrast medium. Computed tomography revealed an aneurysmal change of the SVG with a surrounding thrombus 19 mm in external diameter. During a routine visit for follow-up, the graft aneurysm had ``grown up'' gradually in tomographic external diameter; however, his preceding asymptomatic course and further thickening of the thrombus kept us observing.
On the present admission 3 years after stenting, computed tomography revealed a large aneurysm of the SVG 32 mm in external diameter adjacent to the anterior interventricular groove. Coronary angiography demonstrated a new lesion in the distal LCX. The stented segment of the vein graft enlarged further in size (Fig 1
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Fig 1. . Preoperative angiogram of the previous saphenous vein graft to the left anterior descending artery showed an aneurysmal change of the stented segment surrounded by a hazy shadow suggesting mural thrombi (arrows).
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The patient underwent redo CABG and concomitant resection of the graft aneurysm. Sequential bypass grafting to the LCX via the right coronary artery was performed with an SVG. The LAD distal to the previous anastomosis was incised and, with insertion of a guide-probe retrogradely into the aneurysmal vein graft, the distal body of the previous graft was totally resected. After suture closure of the remaining graft ends, the left internal mammary artery was anastomosed to the incision in the LAD.
The patient's postoperative course was uneventful. He was discharged on the twenty-fifth postoperative day. The removed aneurysmal graft weighed 12 g and measured 40 x 31 x 22 mm. Roentgenography of the specimen revealed a kinked and overexpanded distal segment of the stent inside (Fig 2). Macroscopically, the cut surface of the stented segment showed a huge thrombosed lumen communicating with a fully patent primary lumen (Fig 3). Histologic examination demonstrated a widely dissected graft wall with a large amount of cholesterol deposits showing severe phlebosclerosis. The false lumen was filled with organized thrombi including calcified foci. The entry to the false lumen was largest at the proximal half of the distal segment of the stent.
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Fig 2. . Roentgenogram of the graft specimen revealed a kinked and overexpanded distal segment of the stent inside (bottom of the figure; distal).
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Fig 3. . The cut surface of the stented segment showed a huge thrombosed false lumen communicating with a primary lumen (small asterisk). The entrance (arrow) to the false lumen (large asterisk) was largest at the proximal half of the distal segment of the stent.
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Comment
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Conventional PTCA in patients with prior bypass grafting who have stenosis of the vein graft generally produces satisfactory initial angiographic success [1, 2]. However, the rate of recurrence in vein graft lesions is much higher than that in native coronary arteries [2, 3]. Stenting of vein grafts seems likely to have a high early success rate with fewer subacute thrombotic events than in native artery; its restenosis rate is 25% to 28% with use of the Palmaz-Schatz stent [4, 5] in contrast to 46% with vein graft PTCA [1]. These facts make us support the choice of stenting to manage the vein graft stenosis. In patients with aged vein grafts, however, the development of intimal hyperplasia in the anastomosed site or atherosclerosis throughout the body would have progressed to a relatively severe extent [6]. Stent deployment in such a case will easily cause dissection of the target wall and result in subadventitial hematoma. Even though the target lesion is dilated without dissection, the wall stress amplified by elastic recoil against permanent ``mandatory'' expansion of the stent might lead to tearing of the target wall. Certainly, primary intervention has a lower morbidity and mortality rate as compared with coronary reoperation. We emphasize that stenting of the aged vein graft after failed primary PTCA may cause a dilating complication as in this case, and when acute occlusion is due to parietal dissection, elastic recoil, and thrombosis after vein graft PTCA, a bridge procedure to semielective CABG, such as a perfusion balloon, should be considered. Even when bailout stenting gives angiographic success, the contour and size of the vein graft around the stented site should be examined periodically by echocardiography or tomography.
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Footnotes
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Address reprint requests to Dr Katsumata, Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical College, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162, Japan.
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References
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- Dorros G, Johnson WD, Tector AJ, Schmahl TM, Kalush SL, Janke L. Percutaneous transluminal coronary angioplasty in patients with prior coronary artery bypass grafting. J Thorac Cardiovasc Surg 1984;87:17–26.[Abstract]
- Cooper I, Ineson N, Demirtas E, Coltart J, Jenkins S, Webb-Peploe M. Role of angioplasty in patients with previous coronary artery bypass surgery. Cathet Cardiovasc Diagn 1989;16:81–6.[Medline]
- Platko WP, Hollman J, Whitlow PL, Franco I. Percutaneous transluminal angioplasty of saphenous vein graft stenosis: long-term follow-up. J Am Coll Cardiol 1989;14:1645–50.[Abstract]
- Leon MB, Kent KM, Baim DS, et al. Comparison of stent implantation in native coronaries and saphenous vein grafts [Abstract]. J Am Coll Cardiol 1992;19:263A.
- Pomerantz RM, Kuntz RE, Carrozza JP, et al. Acute and long-term outcome of narrowed saphenous vein grafts treated by endoluminal stenting and directional atherectomy. Am J Cardiol 1992;70:161–7.[Medline]
- Fuster V, Chesebro JJ. Aortocoronary artery vein-graft disease: experimental and clinical approach for the understanding of the role of platelets and platelet inhibitors. Circulation 1985;72(Suppl 5):65–70.
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Abstract
Introduction
