Ann Thorac Surg 1998;65:1127-1128
© 1998 The Society of Thoracic Surgeons
Case Reports
Saphenous Vein Graft Growth 13 Years After Coronary Bypass in a Child With Kawasaki Disease
Hanna M. El-Khouri, MDa,
Delores A. Danilowicz, MDa,
Arnold J. Slovis, MDa,
Stephen B. Colvin, MDb,
Michael Artman, MDa
a Department of Pediatrics, New York University School of Medicine, New York, New York, USA
b Department of Surgery, New York University School of Medicine, New York, New York, USA
Accepted for publication October 8, 1997.
Address reprint requests to Dr Artman, Pediatric Cardiology, New York University Medical Center, FPO Suite 9V, 530 First Ave, New York, NY 10016
e-mail: (michael.artman{at}mcfpo.med.nyu.edu)
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Abstract
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The presumed limited growth potential of saphenous vein grafts has led many authorities to discourage their use in young children. We documented excellent growth and patency of a saphenous vein graft 13 years after operation in a 7-year-old child with coronary artery obstruction caused by Kawasaki disease.
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Introduction
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Kawasaki disease is an important cause of acquired cardiac disease during childhood. Significant coronary artery involvement occurs in 3% to 5% of treated children, resulting in coronary stenoses and aneurysms. The surgical management of coronary artery obstruction includes coronary artery bypass grafting. Venous grafts are rarely used at present, as most of the early reports indicate dismal long-term patency compared with arterial grafts [1]. Furthermore, a major concern is that venous grafts placed in small children will be outgrown during progressive growth of the child. This report describes the long-term patency and remarkable growth of a saphenous vein graft 13 years after placement in a 7-year-old child with Kawasaki disease.
An Asian boy (born in the United States; parents immigrated from Hong Kong) was diagnosed with Kawasaki disease at age 5 years. The initial echocardiogram showed mild dilatation of both right and left coronary arteries without detectable discrete aneurysms. The patient did well clinically and was discharged on a low-dose aspirin regimen. At 7 years of age he presented with chest pain, diaphoresis, nausea, marked ST segment and T wave electrocardiographic abnormalities (compatible with inferior and anteroseptal ischemia) and elevated creatine kinase-MB level. Coronary angiography showed large sacular aneurysms at the origin of the right coronary artery and at the bifurcation of the left coronary artery (Fig 1) with a fusiform aneurysm extending into the circumflex system. There was complete occlusion of the right posterior branch and the left anterior descending artery. The obtuse marginal branch of the circumflex artery was the major patent vessel supplying the myocardium.
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Fig 1. Left coronary angiogram showing a large aneurysm in the left main coronary artery, which includes the bifurcation and extends into the circumflex artery (large white arrow). There is another aneurysm in the left anterior descending coronary artery (small white arrow) with complete obstruction distal to the aneurysm. The black arrow points to the obtuse marginal branch of the circumflex coronary artery.
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At the time of operation, the child was 121 cm tall and weighed 20 kg. An autologous saphenous vein graft with a diameter of 3.5 mm and a length of 8 cm was placed between the ascending aorta and the obtuse marginal branch. The circumflex artery aneurysm was oversewn just proximal to the site of the anastomosis. The postoperative course was smooth and the child did well on follow-up with no symptoms and normal growth and development. For these reasons, repeat coronary angiography was not performed in the early postoperative period.
Thirteen years two months after the operation (when the patient was 20 years old), elective cardiac catheterization was performed. The patient had grown to a height of 178 cm and he weighed 60 kg. Coronary arteriography (Fig 2) showed a patent venous graft that had grown to 5 mm in diameter and 15 cm in length. The aneurysms and previously noted coronary arterial obstructions persisted, but significant collateral vessels had formed from the circumflex and the right coronary arteries to the left anterior descending coronary artery.
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Fig 2. Selective injection into the saphenous vein graft. The entire length of the graft was not recorded on a single cine angiographic frame, so two frames are represented. Panel A shows the saphenous vein graft from the ascending aorta (white arrow) to just proximal to the insertion into the obtuse marginal branch of the circumflex artery (black arrow). Panel B illustrates the patent distal anastomosis of the saphenous vein graft into the obtuse marginal branch. The length of the graft from the proximal to distal anastomosis is 15 cm and the diameter is approximately 5 mm throughout.
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Comment
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Important issues when choosing the type of the graft for coronary artery bypass grafting in small children include growth potential and anticipated long-term patency. Most authors believe that only arterial grafts can achieve those two aims, and thus recommend arterial grafting in children with Kawasaki disease and significant coronary stenosis [1, 2]. The early studies from the Japanese literature on the long-term outcome of venous grafts showed 56% late patency rate in one study [3], but the growth potential of the patent grafts was not described. Kitamura and colleagues [4] described their experience with 6 cases and concluded that saphenous vein grafts are effective in the treatment of Kawasaki coronary artery disease in selected older children and adolescents, but discouraged the use of saphenous vein grafts in children less than 8 years of age because of concerns that the grafts would not grow. A relatively recent multicenter cooperative study from Japan describing 170 patients who underwent aortocoronary bypass grafting reported that at 85 months the overall patency rate was 77% for arterial grafts versus 46% for venous grafts. The difference was even more pronounced for the group less than 7 years old at the time of operation (patency rates were 70% for arterial grafts and 28% for venous grafts in this subset of younger children) [5].
Our patient was 7 years old when he underwent operation using an autologous saphenous vein graft. Follow-up 13 years 2 months later demonstrated that the venous graft had grown considerably from the original dimensions (3.5 mm x 8 cm) to 5 mm in diameter and 15 cm in length. This experience indicates that saphenous vein grafts have growth potential when used as coronary artery bypass grafts in young children.
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References
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- Kato H., Akagi T. Ischemic heart disease in Kawasaki disease. Prog Pediatr Cardiol 1997;6:219-226.
- Takahashi M., Mason W.H. Long-term follow-up of patients with Kawasaki disease. Prog Pediatr Cardiol 1997;6:227-236.
- Suma K., Takeuchi Y., Shiroma K., et al. Early and late postoperative studies in coronary arterial lesions resulting from Kawasaki’s disease in children. J Thorac Cardiovasc Surg 1982;84:224-229.[Abstract]
- Kitamura S., Kawachi K., Harima R., Sakakibara T., Hirose H., Kawashima Y. Surgery for coronary heart disease due to mucocutaneous lymph node syndrome (Kawasaki disease). Am J Cardiol 1983;51:444-448.[Medline]
- Kitamura S., Kameda Y., Seki T., et al. Long term outcome of myocardial revascularization in patient with Kawasaki coronary artery disease. J Thorac Cardiovasc Surg 1994;107:663-674.[Abstract/Free Full Text]
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Abstract
Introduction
