Ann Thorac Surg 2001;71:1356-1358
© 2001 The Society of Thoracic Surgeons
Case report
Fistula between a saphenous vein graft aneurysm and the pulmonary artery trunk
Maher Dabboussi, MDa,
Yves Assad Saade, MDa,
Anne Poncet, MDa,
Bernard Baehrel, MDa
a Department of Thoracic and Cardiovascular Surgery, Robert Debré Hospital, Reims, France
Accepted for publication May 1, 2000.
Address reprint requests to Dr Dabboussi, Service de Chirurgie Thoracique et Cardiovasculaire, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Avenue du Général Koenig, 51092 Reims Cedex, France
e-mail: mdabboussi{at}chu-reims.fr
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Abstract
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We report the case of a 52-year-old man who was admitted for atypical thoracic pain 18 years after a saphenous vein bypass graft of the left anterior descending coronary artery. Investigations demonstrated an aneurysm of the middle portion of the vein graft with a fistulous communication to the pulmonary artery trunk. The aneurysm was excised surgically, and the fistula was closed with an autogenous pericardial patch.
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Introduction
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Coronary artery bypass surgery with a saphenous vein graft (SVG) was introduced in 1967 by Favaloro [1]. Aneurysmal dilatation of such grafts was first reported in 1975 [2]. Twenty-five years later, these aneurysms are a well-recognized, albeit rare, complication of coronary artery operations. The occurrence of a fistula is even less frequent. To our knowledge, this is the first case of a fistula between an SVG aneurysm and the pulmonary artery trunk.
A 52-year-old hypertensive man was admitted to our hospital in November 1999 for intermittent left anterior atypical chest pain radiating into the back. He had a history of an anteroseptal myocardial infarction at the age of 35 years, and in 1982 at another institution, he had undergone a single reversed SVG to the left anterior descending coronary artery. In 1988, coronary angiography was performed because of a positive exercise test and revealed a complete occlusion of the left anterior descending coronary artery. The graft showed a diffuse ectasia, was patent, and provided flow to the first diagonal artery. That artery appeared to be less than 1 mm in diameter. Since that time, the patient had remained symptom free.
At this admission, a continuous murmur, particularly at the left sternal edge, was noted at the physical examination. The electrocardiogram showed sinus rhythm, anteroseptal Q waves, and left ventricular hypertrophy. The chest radiographs demonstrated a large suprahilar and left-sided anterior mediastinal mass. The thoracic computed tomographic scan revealed a 7.0 x 6.0-cm anterior mediastinal mass abutting the left side of the ascending aorta and adjacent to the main pulmonary artery. The vascular nature of the mass was revealed by partial enhancement (Fig 1). The coronary angiographic study showed obstructive changes with no major narrowing of the circumflex and right coronary arteries and their branches. The graft was not catheterized. Aortography indicated that the SVG was patent and demonstrated a fistulous communication between the graft and the main pulmonary artery (Fig 2).
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Fig 1. Computed tomographic scan showing partially enhanced 7.0 x 6.0-cm mass abutting the left side of the ascending aorta.
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Fig 2. Aortograms (A) showing the origin of the saphenous vein graft aneurysm and (B) demonstrating a fistulous communication to the pulmonary artery trunk.
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Surgical intervention was performed with cardiopulmonary bypass and systemic cooling to 30°C. Myocardial protection was provided by cold blood cardioplegia. The aneurysmal dilatation involved the midportion of the graft and was densely adherent to the anterior wall of the pulmonary artery trunk. The aneurysm was excised, and a gelatinous tan-gray thrombus was evacuated. The fistula orifice was 1 cm in diameter. The pulmonary artery trunk was repaired with an autogenous pericardial patch. The proximal part of the graft was ligated, as was the distal portion to obviate backflow. No vessel was harvested for a new bypass graft. Aortic cross-clamp time was 29 minutes. Weaning from cardiopulmonary bypass required inotropic support. Postoperatively, cardiac troponin I levels rose to 33 µg/L. In contrast, electrocardiography and echocardiography showed no changes compared with preoperative studies. The patient was discharged 11 days after operation.
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Comment
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The pathogenesis of SVG aneurysms is not fully understood. Benchimol and associates [2] suggested a potential vein graft weakness in the vicinity of the venous valves because of a lack of circular muscle, weakness at branching sites, or damage at the initial surgical procedure. Most often, the interval between intervention and diagnosis of the aneurysm is greater than 5 years [3].
As a complication of these aneurysms, we note the development of a fistula to one chamber of the heart. Our review of the literature found four instances, one to the right ventricle [3], and three to the right atrium [4–6].
Early operation appears to be the treatment of choice to prevent complications [3–5]. Treatment includes resection of the aneurysm and further revascularization if necessary. Special care should be taken to prevent perioperative myocardial infarction by atheroembolism. No clinical signs of pulmonary embolization were noted in our patient. The myocardial enzymatic reaction was probably due to a limited infarction in the diagonal territory and could have been the result of atheroembolism or suppression of the graft.
In conclusion, the evolution of SVGs in coronary artery bypass operation, still has secrets to reveal. We think pulmonary artery fistula should be included as a late complication of SVG aneurysms.
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References
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Favaloro R.G. Saphenous vein graft in the surgical treatment of coronary artery disease. J Thorac Cardiovasc Surg 1969;58:178-185.[Medline]
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Benchimol A., Harris C.L., Desser K.B., Fleming H. Aneurysm of an aorto-coronary artery saphenous vein bypass graft—a case report. Vasc Surg 1975;9:261-264.[Medline]
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Riahi M., Stone K.S., Hanni C.L., Fierens E., Dean R.E. Right ventricular—saphenous vein graft fistula. Unusual complication of aorta-coronary bypass grafting. J Thorac Cardiovasc Surg 1984;87:626-628.[Abstract]
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Richardson M.P., Thuraisingham S.I., Dunning J. Apparent obstruction of the superior vena cava and a continuous murmur: signs of a fistula between a vein graft aneurysm and the right atrium. Br Heart J 1992;68:412-413.[Abstract/Free Full Text]
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Le Breton H., Pavin D., Langanay T., et al. Aneurysms and pseudoaneurysms of saphenous vein coronary artery bypass grafts. Heart 1998;79:505-508.[Abstract/Free Full Text]
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Gruberg L., Satler L.F., Pfister A.J., Monsein L.H., Leon M.B. A large coronary artery saphenous vein bypass graft aneurysm with a fistula: case report and review of the literature. Catheter Cardiovasc Interv 1999;48:214-216.[Medline]
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Abstract
Introduction
