Ann Thorac Surg 2000;70:1706-1708
© 2000 The Society of Thoracic Surgeons
Case report
Twenty-two-year follow-up of saphenous vein grafts in pediatric Kawasaki disease
Yuji Suda, MD, PhDa,
Yasuo Takeuchi, MD, PhDa,
Tetsuo Ban, MDa,
Seiichi Ichikawa, MDa,
Ryuji Higashita, MDa
a Department of Cardiovascular Surgery, Tokyo Women’s Medical University, Daini Hospital, Tokyo, Japan
Address reprint requests to Dr Suda, Department of Cardiovascular Surgery, Tokyo Women’s Medical University, Daini Hospital, 2-1-10 Nishiogu, Arakawa-ku, Tokyo 116-8567, Japan
e-mail: y-suda{at}pb3.so-net.ne.jp
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Abstract
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We describe 2 Kawasaki disease patients with excellent long-term patency of saphenous vein grafts, who underwent coronary artery bypass at age 7 and 9 years, respectively, and demonstrated normal growth during 22 years of follow-up. The grafts showed no deterioration and played an important role in coronary blood supply.
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Introduction
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Kawasaki disease (KD) is the leading cause of pediatric ischemic heart disease. Coronary artery bypass grafting (CABG) for children with severe coronary artery involvement by KD has been performed in Japan since 1974. Initially, saphenous vein grafts (SVGs) were mainly used, but patency declined sharply during the early years after surgery [1]. Here we describe 2 unusual KD patients with SVGs showing excellent patency on coronary angiography at 18 and 20 years after surgery, which is probably the longest period of graft survival among Japanese patients.
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Case reports
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Patient 1
A 5-year-old Japanese boy was diagnosed as having KD. Four years later, electrocardiography showed anterior and inferior wall ischemia. Subsequent coronary angiography revealed complete occlusion of the right coronary artery, a saccular aneurysm with distal critical stenosis of the proximal left anterior descending artery, and a fusiform aneurysm of the left circumflex artery.
In November 1977, CABG was performed with saphenous vein grafting to the left anterior descending artery. The patient was 9 years old, 139 cm tall, and weighed 40 kg. Coronary angiography at 1 month postoperatively showed a patent SVG (Fig 1A) that was 2.0 mm in diameter and 97 mm long. Follow-up cine angiography was performed after 7 and 20 years. During this 20-year period, the patient had grown to 173 cm in height and weighed 98 kg. The latest angiograms showed excellent patency of the SVG, which was 2.9 mm in diameter and 117 mm long. The left anterior descending artery had undergone complete proximal obstruction and cardiac blood supply was dependent on SVG flow (Fig 1B).
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Fig 1. Selective angiograms of the saphenous vein graft (SVG) to the left anterior descending artery at 1 month (A) and 20 years (B) after operation.
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At 22 years after the operation, he is 31 years old and works full-time without cardiac symptoms.
Patient 2
A 7-year-old Japanese boy was referred to our institution for treatment of coronary artery disease. He had a history of continuous high-grade fever at 2 months old and acute myocardial infarction at 9 months. KD was diagnosed by aortography at 5 years old. On admission to our hospital, preoperative coronary angiography revealed a left ventricular aneurysm, plus complete obstruction of the left anterior descending artery, and critical stenosis of the right coronary artery caused by coronary aneurysms in the left main trunk and proximal right coronary artery, respectively.
In April 1978, we performed left ventricular aneurysmectomy and saphenous vein grafting to the right coronary artery. The patient was 123 cm tall and weighed 24 kg. Coronary angiography was performed 3 months postoperatively, revealing a patent SVG (Fig 2A) measuring 3.1 mm in diameter and 75 mm long. Follow-up cine angiography was performed after 7 and 18.5 years. During this 18-year period, the patient had grown to 171 cm in height and weighed 54 kg. The SVG showed excellent patency, being 4.0 mm in diameter and 81 mm long. Collateral vessels had grown from the right coronary artery into the territory of the left anterior descending artery (Fig 2B). He was able to pass an 18 Mets treadmill exercise test.
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Fig 2. Angiograms showing the functioning saphenous vein graft (SVG) to the right coronary artery at 3 months (A) and 18 years (B) after operation.
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At 22 years after the operation, he is 29 years old and leads a normal life, working full-time.
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Comment
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A major problem with performing CABG in pediatric KD patients is their considerable growth postoperatively. Accordingly, we have used multiple arterial grafts sourced from the gastroepiploic artery and the conventional internal thoracic artery (ITA) since 1988 [2]. Using the in situ ITA and gastroepiploic artery, which have the potential for growth, has improved long-term graft patency and survival [1]. However, SVGs originally served as the principal conduit for myocardial revascularization in KD. Our 2 SVGs were implanted by a interrupted stitch technique with 7/0 silk suture.
Among our 27 KD patients treated using SVGs, including the 2 cases reported here, the long-term patency rate was 44% after an average follow-up of 11 years. Occlusion was frequent within 3 years postoperatively, but grafts that survived showed no subsequent occlusion and maintained long-term patency with excellent run-off. Previous studies in adults have shown that many SVGs with long-term patency develop so-called vein graft disease [3, 4]. However, there was no stenosis or graft deterioration in our 2 cases, suggesting that some SVGs in pediatric patients are resistant to vein graft disease.
We calculated the three-dimensional length of the SVGs in our 2 patients by biplane cine angiography [5]. In patient 1, the SVG increased in length by 20 mm (from 97 to 117 mm) over 20 years. In patient 2, the graft grew by 6 mm (from 75 to 81 mm) over 18 years. These changes were small in proportion to each patient’s somatic growth and were less than the ITA growth described by Kitamura and colleagues [5]. Our results are also different from the report of El-Khouri and associates, who found that a vein graft grew by 70 mm (from 80 to 150 mm) over 13 years [6]. However, the SVGs were not outgrown in our 2 patients and the recipient vessels did not show tenting traction. Our experience indicates that the plasticity of SVGs is limited, but these grafts can adapt to growth of the host by an increase in length and diameter, and can handle the increased coronary blood flow.
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References
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Kitamura S., Kameda Y., Seki T., et al. Long-term outcome of myocardial revascularization in patients with Kawasaki coronary artery disease. J Thorac Cardiovasc Surg 1994;107:663-674.[Abstract/Free Full Text]
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Takeuchi Y., Gomi A., Okamura Y., et al. Coronary revascularization in a child with Kawasaki disease. Ann Thorac Surg 1990;50:294-296.[Abstract]
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Campeau L., Enjalbert M., Lesperance J., et al. The relation of risk factors to the development of atherosclerosis in saphenous vein bypass grafts and the progression of disease in the native circulation. N Engl J Med 1984;311:1329-1332.[Abstract]
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Horii T., Suma H., Wanibuchi Y., Fukuda S., Kigawa I. The long-term patency rate of saphenous vein grafts and vein graft disease in Japanese patients. J Jpn Assn Thorac Surg 1993;41:1447-1451.
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Kitamura S., Seki T., Kawachi K., et al. Excellent patency and growth potential of internal mammary artery grafts in pediatric coronary artery bypass surgery. Circulation 1989;78(Suppl 1):29.
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El-Khouri H., Danilowicz D., Slovis A., et al. Saphenous vein graft growth 13 years after coronary bypass in a child with Kawasaki disease. Ann Thorac Surg 1998;65:1127-1130.[Abstract/Free Full Text]
Accepted for publication February 8, 2000.
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Abstract
Introduction
