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Ann Thorac Surg 1999;68:1433-1437
© 1999 The Society of Thoracic Surgeons

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Current Reviews

Giant aneurysm of saphenous vein graft to coronary artery compressing the right atrium

^a Division of Cardiothoracic Surgery, Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, New York, USA

Address reprint requests to Dr Kalimi, Department of Surgery, Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040

	Abstract

Top Abstract Introduction Patients and methods Case report Comment References

 
Aneurysm of reverse aortocoronary saphenous vein graft is a known complication of coronary artery bypass grafting. In this report we present a case of a 60-year-old man who presented 12 years after coronary artery bypass grafting with a giant graft aneurysm of the reverse aortocoronary saphenous vein graft to the right coronary artery, compressing the right atrium. Spiral computed tomography was used to identify the aneurysm measuring 7 x 6 x 7 cm. We also reviewed the English-language literature and found reports of 50 patients with similar aneurysms of which 30 (61%) were identified as true aneurysms and 17 (33%) were identified as pseudoaneurysms. Three patients could not be identified into either group. We reviewed the presenting symptoms, diagnostic tools, and treatment options for this rare entity. An understanding of the pathophysiology of reverse aortocoronary saphenous vein graft aneurysm is important to prevent the possibility of aneurysm rupture, embolization, myocardial infarction, or death.

	Introduction

Top Abstract Introduction Patients and methods Case report Comment References

 
Aneurysm of aortocoronary reverse saphenous vein graft (RSVG) after aortocoronary bypass is a rare but potentially fatal complication of coronary artery bypass grafting (CABG). This entity has been classified as true aneurysm and pseudoaneurysm. Pseudoaneurysm can be associated with a technical problem at the proximal or distal suture line, or with infectious processes. We describe a case of a true giant aneurysm compressing the right atrium and superior vena cava.

	Patients and methods

Top Abstract Introduction Patients and methods Case report Comment References

 
We performed a MEDLINE search with the search terms "reverse saphenous vein graft," "aneurysm," "aortocoronary," and "pseudoaneurysm." We included all case reports and review articles from the English-language literature. Our search yielded 42 publications reporting on 50 patients from 1975 to 1998 that were categorized as true aneurysm of RSVG (30 patients), and pseudoaneurysm of RSVG (17 patients). Three patients could not be categorized into either group.

	Case report

Top Abstract Introduction Patients and methods Case report Comment References

 
A 60-year-old man with a history of hypertension, hypercholesterolemia, and CABG 12 years previously with RSVG to the left anterior descending (LAD) artery and to the right coronary (RC) artery presented with an enlarging right hilar mass found on routine chest x-ray. Computed tomography (CT) showed an intrapericardial mass with compression of the superior vena cava (Fig 1). He subsequently presented to the emergency department with chest pain. On physical examination the patient was afebrile and hemodynamicaly stable. Cardiac examination found normal S1 and S2 heart sounds with no murmur, gallop, or rub. Electrocardiogram was consistent with ST depressions in I, AVL, V5, V6, and Q wave in III. A spiral CT scan obtained on admission found a 7 x 6 x 7-cm laminated mass with a central lumen compressing the right atrium as well as the superior vena cava. Cardiac catheterization revealed a total proximal occlusion of the LAD. The vein graft to this vessel was widely patent. There was also an 85% proximal stenosis in the ramus intermediate. There was total proximal occlusion of the RC artery. The vein graft to the distal vessel was patent, but the proximal region of the vein graft was aneurysmal.

View larger version (131K): [in this window] [in a new window]   Fig 1. Computed tomographic scan showing an aortocoronary aneurysm.

The RC artery was grafted distal to the old RC graft using RSVG. The left internal thoracic artery was used to graft the LAD, and a radial artery was used to graft the obtuse marginal artery. Early after cardiopulmonary bypass there was evidence of reduced inferior wall motion believed to be due to microembolization of thrombus into the RC artery or to inadequate myocardial protection. The patient was weaned from cardiopulmonary bypass with intraaortic balloon pump support. Postoperatively, the patient recovered satisfactorily and was discharged on the sixth postoperative day.

	Comment

Top Abstract Introduction Patients and methods Case report Comment References

 
In this study we reviewed 42 [1–42] reports in the English-language literature, which included 50 patients with aortocoronary bypass aneurysms, and added our own experience (Table 1). Thirty patients (61%) had true aneurysms, and 17 patients (33%) had pseudoaneurysms. Three patients could not be categorized into either group.

Presentation
Many patients in the true aneurysm group were asymptomatic (47%). In most of those patients a hilar mass was found on routine chest roentgenogram, which was further investigated by CT scan and cardiac catheterization. The next most common presenting symptom in this group was myocardial infarction (MI), which occurred in 23% of the group, followed by angina in 13%, chest pain in 13%, and congestive heart failure in 3%. Taliercio and associates [3] reported on the occurrence of a MI caused by distal embolization from the aneurysmal graft. Sahouri and Steele [4] reported an RSVG aneurysm to the circumflex artery presenting as MI secondary to mass effect of the aneurysm on the left internal thoracic artery to the LAD.

Hyperlipidemia was implicated by several authors [5–8] as a significant finding in patients with RSVG aneurysm. Our patient also had hyperlipidemia. The degenerative process in that case was chronic and progressive. Most patients with a true RSVG aneurysm will remain asymptomatic, and in most cases a hilar mass will be found on routine chest roentgenogram. We identified the aneurysm in our case as a true aneurysm based on the operative finding of a large circumferential thrombus in the mid portion of the graft in conjunction with a history of hyperlipidemia.

In the pseudoaneurysm group chest pain was the leading presenting symptom (29%), followed by angina (24%). Only 12% of this group was asymptomatic. Other unique presenting symptoms in this group of patients included bleeding (12%), hemoptysis (6%), and infection (6%). Only 12% of the patients in this group had MI. Pseudoaneurysm formation is usually related to disruption of the proximal or distal suture line due to technical failure or infectious processes [9, 10]. These patients more often present with chest pain when the blood supply to the myocardium is compromised. Time of presentation after CABG was similar in both groups (10.1 years in the true aneurysm group [range, 4 months to 21 years] and 9.7 years in the pseudoaneurysm group [range, 7 days to 21 years]). The most frequently affected graft was RSVG to the LAD (44% in the true aneurysm group and 36% in the pseudoaneurysm group).

Diagnosis
Both true aneurysms and pseudoaneurysms can be detected as hilar masses on chest roentgenogram. However, the differential diagnosis of a hilar mass consists of more common diagnoses such as lymphoma, thymoma, and pericardial cyst. A CT scan with intravenous contrast is helpful in identifying the consistency, vascularity, and patency of the aneurysm. Furthermore, CT scan is a particularly important modality for differentiating solid from cystic lesions and for demonstrating the location of the mass and its effect on nearby structures. Several reports [11–14] discussed the use of magnetic resonance imaging for identifying RSVG aneurysms. Some authors also advocated the use of transesophageal echocardiography [14, 15] for evaluating these aneurysms. In our case the use of spiral CT was useful in identifying the aneurysm and clearly showing its effect on nearby structures.

We strongly believe that when a differential diagnosis of aortocoronary aneurysm is considered, a patient should undergo cardiac catheterization. Cardiac catheterization will show the aneurysm, but more importantly it will identify other areas of ischemia that might require revascularization during aneurysmorrhaphy. In three reports [8, 16, 17] patients who presented with hilar masses and who were thought to have mediastinal or pulmonary masses and did not undergo catheterization were subjected to left anterior thoracotomy [8] and posteriolateral thoracotomy [16]. Both cases required closure and proper exposure through a median sternotomy.

Treatment
Although two reported cases [15, 18] of RSVG aneurysms were not treated surgically, most of the true aneurysms and pseudoaneurysms were treated with either exclusion or resection of the aneurysm and revascularization. Several studies [9, 19–22] reported successful embolization of pseudoaneurysms using coils. However, embolization of aneurysms could preclude blood flow not only to the aneurysm but also to the coronary artery distal to the aneurysm. In two reports [17, 23] the aneurysm was either resected or excluded, without revascularizing the coronary artery distal to the aneurysm. Those patients had a postoperative anterior wall MI. Although the natural history of CABG aneurysm is not clearly documented and only a minority of cases might come to clinical attention, from our review several important facts regarding RSVG aneurysms can be learned. First, there is clearly a histopathologic difference between true aneurysms and pseudoaneurysms. True aneurysm is a slow degenerative process frequently associated with hyperlipidemia, whereas pseudoaneurysm can be caused by technical failure or by an infectious process leading to a disruption of the proximal or distal anastomoses. We believe that the difference in presenting symptoms in the two groups is related to the differences in origin of the aneurysm. True aneurysms are more likely to be asymptomatic, whereas pseudoaneurysms more often present with chest pain. Either entity carries a significant morbidity or mortality rate and should be considered in the differential diagnosis of a patient with a hilar mass presenting after CABG. This diagnosis is facilitated by several modalities. Particularly useful is a CT scan and cardiac catheterization. These diagnostic modalities are important not only in diagnosis but also in planning treatment. Although RSVG aneurysm is a rare complication of CABG, given the risk of rupture [26, 27], embolization [25], myocardial infarction [16, 23], and death [1, 6, 25–29], we believe that these aneurysms should be surgically excluded from the circulation, and the coronary artery distal to the aneurysm should be revascularized. The type of aneurysm cannot be predicted based on age, gender, presentation, size of aneurysm, and time of presentation after CABG.

	References

Top Abstract Introduction Patients and methods Case report Comment References

 

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