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Ann Thorac Surg 1998;65:831-832
© 1998 The Society of Thoracic Surgeons

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Case Reports

Saphenous Vein Graft Pseudoaneurysm Rupture After Coronary Artery Bypass Grafting

Department of Thoracic and Cardiovascular Surgery, Jichi Medical School, Tochigi, Japan

Accepted for publication October 1, 1997.

Dr Fuse, Department of Thoracic and Cardiovascular Surgery, Jichi Medical School Hospital, 3311-1 Yakusiji, Minami-kawachimachi, Kawachi-gun, Tochigi 329-04, Japan.

	Abstract

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An elderly woman underwent coronary artery bypass grafting, which was followed 1 month later by pseudoaneurysmal rupture at the distal anastomosis of a saphenous vein graft. Emergency repair of the suture line dehiscence was made, and the postoperative course was uneventful. Pseudoaneurysm formation of a saphenous vein graft after coronary artery bypass grafting is a rare but potentially lethal complication requiring urgent operative intervention.

	Introduction

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A 73-year old woman was admitted because of chest pain at rest. She was diagnosed as having unstable angina secondary to triple-vessel coronary artery disease with associated left main truncal stenosis. Urgent coronary artery bypass grafting was performed in which the left internal thoracic artery was applied to the left anterior descending artery and reversed saphenous vein grafts (SVGs) were applied to the obtuse marginal and right coronary arteries. Perioperatively, intraaortic balloon pumping was employed because of severe cardiac failure. The postoperative course was uneventful, and on the 5th postoperative day she was weaned from intraaortic balloon pump support. Anticoagulation with warfarin sulfate was commenced on the 10th postoperative day.

One month postoperatively, routine coronary angiography revealed a pseudoaneurysm at the anastomotic site of the SVG to the obtuse marginal artery (Fig 1). The following day her condition became complicated by cardiogenic shock secondary to cardiac tamponade. An emergency operation revealed the pericardial sac filled with hematoma and a 3-cm-diameter aneurysm at the anastomotic site (Fig 2). The aneurysm had ruptured through the posterior wall, and intraluminal 0.5 mm diameter dehiscence of the suture line was apparent. The aneurysm was resected and the anastomosis was repaired by a single stitch. Postoperatively intraaortic balloon pumping was reapplied, the patient remained stable, and no further complications occurred. She was discharged 2 months after the emergency operation.

View larger version (143K): [in this window] [in a new window]   Postoperative coronary angiogram shows a pseudoaneurysm on the distal anastomotic site of the saphenous vein graft to the obtuse marginal artery.

View larger version (1K): [in this window] [in a new window]   Operative finding on reoperation. The arrow shows a pseudoaneurysm on the distal anastomotic site of the saphenous vein graft to the obtuse marginal artery.

	Comment

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We reviewed 14 cases of pseudoaneurysm of SVG after coronary artery bypass grafting reported from 1979 to 1995. Three cases were detected within 1 week postoperatively, the others being diagnosed between 2 months and 17 years. Early-onset cases may be due to infection and operative factors, whereas the ones with later onset are due to atherosclerosis or unknown causes [1][2][3]. The clinical presentation is usually chest pain, and thorough investigation, for example, computed tomography, magnetic resonance imaging, or angiography, reveals the pseudoaneurysm. As for the site of the aneurysm, 8 were at the proximal aortic anastomosis, 3 were in the body of the graft, and 3 at the distal anastomosis. The proximal site, under higher pressure than the distal site, is predisposed to a higher incidence of aneurysmal formation. Graft body aneurysms were due to host vessel degeneration and technical factors involved in harvesting the saphenous vein. Distal site aneurysms were due to operative factors such as suture line breakdown secondary to failure of the suture material failure and to tension on the anastomosis [2].

The mechanism of pseudoaneurysm formation is unclear. Kallis and associates [4] speculated that hypertension, trauma to the SVG, weakness of a branch, weakness around valves secondary to absence of circular muscle in the media, atherosclerotic changes, mycotic vasculitis, and dissection of the vein graft may be risk factors. In our patient, there was no sign of infection. Mechanical stress due to postoperative hypertension and operative factors could be the cause of aneurysmal formation. For the few days before the reoperation, anticoagulation was maintained with a prothrombin time (international normalized ratio) between 1.0 and 1.3. Therefore, it is not clear whether anticoagulation therapy contributed to the aneurysmal formation.

Pseudoaneurysm of SVG is one potentially fatal complication of coronary artery bypass grafting because of the high risk of rupture. In half the reported cases, chest pain was usually the chief complaint. Pseudoaneurysm should therefore be considered in the differential diagnosis of this symptom in these patients so that resection and repair can be performed without delay.

	References

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1. De Haan HPJ, Huysmans HA, Weeda HWH, Bosker HA, Buis B Anastomotic pseudoaneurysm after aorto-coronary bypass grafting. Thorac Cardiovasc Surg 1985;33:55-56.[Medline]
2. Johnson PR, Truitt TD Saphenous vein coronary artery bypass graft aneurysm demonstrated by electron beam CT. J Comput Assist Tomogr 1994;18:488-491.[Medline]
3. Smith JA, Goldstein J Saphenous vein graft pseudoaneurysm formation after postoperative mediastinitis. Ann Thorac Surg 1992;54:766-768.[Abstract/Free Full Text]
4. 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;70:189-192.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yoshio Misawa Osamu Kamisawa Katsuo Fuse Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mohara, J. Articles by Fuse, K. Search for Related Content PubMed PubMed Citation Articles by Mohara, J. Articles by Fuse, K.