Ann Thorac Surg 2004;77:1815-1817
© 2004 The Society of Thoracic Surgeons
Case report
A man with saphenous vein graft aneurysms after bypass surgery
Matthew L. Williams, MDa,b,
Edward Rampersaud, BSb,
Walter G. Wolfe, MDb*
a Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
b Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
Accepted for publication May 8, 2003.
* Address reprint requests to Dr Wolfe, Department of Surgery, Duke University Medical Center, Box 3507, Durham, NC 27710, USA
e-mail: wolfe001{at}mc.duke.edu
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Abstract
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Saphenous vein graft (SVG) aneurysms are a rare complication of coronary artery bypass graft surgery. Patients in whom these aneurysms form a fistula with either a cardiac chamber or mediastinal vessel are even more uncommon and present a difficult diagnostic and therapeutic challenge. We present a patient with SVG aneurysms and a fistula to the left atrium.
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Introduction
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Saphenous vein graft (SVG) aneurysms are a rare complication after coronary artery bypass surgery, and fistulas arising from these aneurysmal grafts have been previously reported in only six patients. The following is a case report of a man in whom SVG aneurysms and a fistula to the left atrium developed 12 years after bypass surgery.
The patient is a 58-year-old man who underwent coronary artery bypass surgery in 1987. Aortocoronary SVGs to the posterior descending artery and second obtuse marginal were used, and the left internal mammary artery (LIMA) was anastomosed to the left anterior descending coronary artery. The patient did well after his original surgery and had no recurrence of his anginal symptoms. Twelve years later he noted a sharp pain between the scapulae that radiated to the anterior chest and was associated with a pressurelike sensation that mimicked his old anginal symptoms. He presented to an outside hospital where an electrocardiogram showed no change from his baseline, and cardiac enzymes were normal. He was eventually discharged, but over the next few days he developed orthopnea and paroxysmal nocturnal dyspnea. Cardiologic evaluation revealed a new murmur on examination that was described as continuous. He was referred to Duke Hospital for further evaluation.
On presentation at our institution, transthoracic echocardiography was performed that showed depressed left ventricular function with an ejection fraction of 0.40 and no evidence of valvular insufficiency. There was no evidence of a ventricular septal defect. A computed tomographic study of the chest was performed that demonstrated two tubular, contrast-enhancing structures in the mediastinum that appeared to represent aneurysmal but patent aortocoronary bypass grafts. Cardiac catheterization confirmed the presence of massively dilated SVGs to the distal right and left circumflex artery as well as a fistula from the left-sided graft to the left atrium (Fig 1).
Both SVGs remained patent. He had a mean wedge pressure of 30 mm Hg and a cardiac index of 2.15 L · min–1 · m–2. Surgery was performed to correct this anatomy.
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Fig 1. Dilated saphenous vein grafts to the distal right and left circumflex artery and a fistula from the left-sided graft to the left atrium are shown. (LA = left atrium; OM2 = second obtuse marginal branch of the left circumflex artery; SVG = saphenous vein graft.)
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Because the aneurysmal grafts were seen just beneath the sternum on preoperative imaging studies, we were concerned that catastrophic bleeding could be encountered on opening the chest. Therefore a cannula was inserted in the groin, and cardiopulmonary bypass was initiated before sternotomy. The sternum was carefully reopened without injuring the aneurysms or the LIMA graft. The heart was dissected free from the mediastinum, and the aorta was exposed to allow a cross-clamp to be placed. We attempted to place a retrograde cardioplegia catheter, but despite several attempts with echocardiographic guidance we were unable to place one. The aorta was cross-clamped, and antegrade cardioplegia was administered through the aortic root. The aneurysmal SVGs were dissected down to their sites of anastomosis on the aorta and the coronary arteries. At the areas of anastomosis the caliber of the grafts was normal. Distal and proximal control of the grafts was obtained. The aneurysms were opened and thrombus was removed. The fistula from the left circumflex graft to the left atrium was closed from within the aneurysm with pledgeted sutures. The abnormal portions of the old SVGs were resected, and the new SVGs were sewn in place in an end-to-end fashion distally and into the aorta proximally. After rewarming, the patient had difficulty coming off bypass despite the use of epinephrine and dopamine. The right ventricle was markedly dilated, and left ventricular function was clearly depressed. A balloon pump was inserted. Despite this intervention it was necessary to leave the operating room with the support of extracorporeal membrane oxygenation (ECMO).
After his operation, the patient's ventricular function slowly improved, and he was removed from ECMO on postoperative day 2; his balloon pump was removed on postoperative day 3. He slowly recovered with minimal complications and is doing well today and living at home. Four years after undergoing this procedure, he is in New York Heart Association class I heart failure, and at a recent follow-up visit he reported walking 2 miles each day.
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Comment
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Although large numbers of patients have undergone coronary bypass surgery using SVGs, there is only a small number of case reports of aneurysmal dilatation in these conduits. In only four previous cases have there been communications to cardiac chambers: three to the right atrium [1–3] and one to the right ventricle [4]. In addition, there are reports of a fistula to the pulmonary artery [5] and another to the chest wall [6]. In the patient under discussion, an SVG to the left circumflex system was the source of the fistula to the left atrium, the first reported case of an SVG to that cardiac chamber. This patient developed severe biventricular dysfunction. There are various possible causes for the pump failure that necessitated ECMO support. These include incomplete myocardial protection due to our inability to pass a retrograde perfusion catheter to deliver cardioplegia. This situation left large areas of the heart without cardioplegia while the SVGs were resected and repaired. Retrograde cardioplegia would have been ideal. In addition it is possible that debris from the mural thrombi that were present in the aneurysmal SVGs embolized into the distal coronary circulation, despite our best efforts to gain control of the grafts without disruption of mural thrombi. It is imperative to carefully dissect the distal anastomoses of aneurysmal grafts and gain distal control to prevent embolization. A complicating factor in our patient was the fistula to the left atrium, which elevated left-sided pressures and contributed to his right ventricular dysfunction.
The most common presenting symptoms of patients with aneurysmal SVGs include myocardial infarction, angina, and heart failure, although many patients were asymptomatic at the time of presentation and their aneurysms were discovered incidentally, usually as a mediastinal mass on a chest roentgenogram [7]. In our patient it is probable that the fistula to the atrium and resultant volume overload contributed to his presenting symptoms of congestive heart failure. Perhaps the initial presentation of midscapular back pain was caused by rupture of the aneurysm into the left atrium.
Evaluation of any suspected SVG aneurysm should include coronary angiography to determine patency as well as any other coronary stenoses that should be addressed at the time of operation. Another particularly useful imaging modality is computed tomography, which can demonstrate flow in the aneurysm and delineate anatomic relationships of the aneurysm with other structures.
As previous authors have described [7], untreated aneurysms have caused myocardial infarction [8, 9], rupture [10, 11], and death. Although performing an operation in this setting is hazardous, the potential consequences of inaction justify surgical exclusion of the aneurysm with revascularization of the distal coronary artery.
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References
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- Jukema J.W., van Dickman P.R.M., van der Wall E.E. Pseudoaneurysm of a saphenous vein coronary artery bypass graft with a fistula draining into the right atrium. Am Heart J 1992;124:1397-1399.[Medline]
- Le Breton H., Langanay T., Roland Y., et al. Aneurysms and pseudoaneurysms of saphenous vein coronary artery bypass grafts. Heart 1998;79:505-508.[Abstract/Free Full Text]
- 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]
- Dabboussi M., Saade Y.A., Poncet A., Baehrel B. Fistula between a saphenous vein graft aneurysm and the pulmonary artery trunk. Ann Thorac Surg 2001;71:1356-1358.[Abstract/Free Full Text]
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- Kalimi R., Palazzo R.S., Graver L.M. Giant aneurysm of saphenous vein graft to coronary artery compressing the right atrium. Ann Thorac Surg 1999;68:1433-1437.[Abstract/Free Full Text]
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Abstract
Introduction
