Ann Thorac Surg 2006;81:1885-1887
© 2006 The Society of Thoracic Surgeons
Case report
Right Thoracotomy for Saphenous Vein Graft Aneurysm Causing Hemoptysis
Torbjörn Ivert, MD, PhD
*
,
Lotta Orre, MD
Department of Thoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
Accepted for publication May 10, 2005.
* Address correspondence to Dr Ivert, Department of Thoracic Surgery, Karolinska University Hospital, Stockholm, 171 76 Sweden (Email: torbjorn.ivert{at}kirurgi.ki.se).
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Abstract
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Hemoptysis and septicemia 6 years after coronary artery bypass surgery in a 56-year-old man was caused by a 5-cm vein graft pseudoaneurysm bleeding into the right pleura and lung parenchyma. The graft was approached through a right thoracotomy. The patient suffered postoperative neuromyopathy, but fully recovered within 6 months without muscular, respiratory, or cardiac symptoms.
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Introduction
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Large saphenous vein graft aneurysms are rare considering that many hundreds of thousands of coronary bypass procedures have been performed and only about 60 cases were reported as of 2003 [1, 2]. The onset in our patient, with a large hematoma eroding diffusely into the lung tissue causing hemoptysis, has not been previously reported. There are two previous reports of a patient with hemoptysis who had a fistula develop between a vein graft aneurysm and a bronchus [1, 3]. There are also reports of a vein graft aneurysm causing a fistula into an atrium and the right ventricle, respectively [4, 5].
A 56-year-old man with a medical history including hypertension, diabetes mellitus, alcoholic induced pancreatitis, bleeding peptic ulcer, and neuropathy underwent coronary artery bypass surgery in 1998. Vein graft quality was without remarks at the operation. Angiography performed because of recurrent chest pain 4 years after the operation disclosed stenosis of the vein graft to the right coronary artery, occlusion of the left main coronary artery, and a patent vein graft supplying two marginal branches as well as a patent left internal mammary artery graft to the left anterior descending coronary artery. In August 2004, he was admitted because of hemoptysis, fever, dyspnea, and anemia. The systolic blood pressure was 110 mm Hg, and the heart rate was 110 beats/min. Chest roentgenogram showed fluid in the right pleura and pneumonic infiltration in the right lower lobe. Acute gastroscopy performed to exclude bleeding was negative. Blood was obtained after needle aspiration from the pleura. Computed tomography with contrast showed a 5-cm aneurysm partially filled with thrombus lateral to the right ventricle. There were atelectasis of the lung and blood in the pleura (Fig 1). An aneurysm at the right vein graft was confirmed by angiography that demonstrated sparse distal contrast filling (Fig 2). There was a 50% stenosis of the native right coronary artery at the posterior descending branch. Blood cultures were positive for Klebsiella pneumoniae.
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Fig 1. Computed tomography demonstrating an aneurysm to the right of the heart with diameter (cm) partially filled with thrombus and contrast. There are atelectasis of the right lower lobe and blood in the pleura.
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Fig 2. Angiography of a right saphenous vein graft 6 years after surgery with an aneurysm and contrast filling of the distal vein graft.
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Because of the patient's deteriorating clinical condition, with increasing difficulties in breathing and signs of continuing bleeding, surgery was urgently performed despite ongoing septicemia and pneumonia. A double-lumen tracheal tube was inserted. A right thoracotomy was performed in the fifth costal interspace. There were dense pleural adhesions. The ascending aorta was dissected anterior to the superior vena cava and exposed with the aid of stay sutures in the pericardium. The proximal anastomosis of the vein graft was identified and ligated. Large amounts of old clots and fresh blood were evacuated from the pleura. The hematoma had eroded into lung parenchyma at the medial right lower lobe, but there was no apparent communication between the aneurysm and the bronchus. Lung resection was not necessary. The aneurysm was opened and its clot was removed. The vein was ligated distal to the aneurysm. The wound was irrigated with saline after careful removal of all clots. Two large chest tubes were inserted and the chest wall was closed. Histopathology of the aneurysm was consistent with a pseudoaneurysm.
Several cultures from the pleura were positive for Klebsiella pneumoniae. No culture was taken from inside the aneurysm. He was free from fever after 4 days of intravenous treatment with cefotaxim. An initial major air leak from the lung healed, and the chest tubes were removed after 8 days. Within 3 weeks leukocyte count decreased from 17 x 109/L to normal levels less than 9 x 109/L, and the C-reactive protein level decreased from 370 mg/L to less than 10 mg/L. Chest roentgenogram showed a fully expanded right lung. The patient required a tracheotomy and 12-day respiratory treatment after the operation. He was awake, but he had marked generalized muscular weakness. Electrophysiologic investigations showed a pattern of polyneuromyopathy. He needed 8 weeks hospital treatment and recovered fully within 6 months without signs of residual infection, muscular, respiratory, or cardiac symptoms.
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Comment
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There were three obvious treatment options for this patient with a large saphenous vein graft aneurysm. Coiling of the aneurysm and occluding the vein graft with catheter technique could eliminate risk of bleeding, but it left the respiratory situation with a large infected hematoma in the right pleura. An anterior sternotomy would have given easy access to the anterior heart and the proximal vein graft anastomosis. It was suboptimal to use cardiopulmonary bypass in this patient with septicemia and pneumonia to insert a graft to the distal right coronary artery that was only 50% obstructed. A third option preferred by us was to manage the aneurysm and the bleeding to the pleura through a thoracotomy without the use of cardiopulmonary bypass or attempts at revascularization. Angiography had shown that later elective percutaneous coronary intervention was possible in case of future disabling angina.
The vein was ligated proximally and distally to the widely opened aneurysm sac. Thorough debridement of the pleural cavity, chest tube drainage and antibiotic treatment was sufficient to cure the infection.
In our patient, there were no signs of vein graft aneurysm at an angiography performed 2 years after the operation. Therefore the aneurysm must have developed within a relatively short period of time from a degenerated vein wall. The reported case is unusual, occurring already 6 years after surgery as a majority of large saphenous vein graft aneurysms are detected more than 10 years after the operation [1, 4]. The postoperative course of our patient was complicated by the condition of critical illness polyneuromyopathy requiring 2 months of rehabilitation in the hospital [6].
Usually vein graft aneurysms are asymptomatic and may be discovered incidentally or after investigation because of angina or congestive heart failure. The clinical course is usually not benign, and in view of reported complications such as embolization, rupture and sudden death, active intervention is indicated after diagnosis [1, 2, 4].
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References
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- Dieter RS, Patel AK, Yandow D, et al. Conservative vs. invasive treatment of aortocoronary saphenous vein graft aneurysms: treatment algorithm based upon a large series Cardiovasc Surg 2003;11:507-513.[Medline]
- Mayglothling J, Thomas MP, Nyzio JB, Strong MD, Samuels LE. Aneurysm of aortocoronary saphenous vein graftcase report and literature review. The Heart Surgery Forum 2004;7:E317-E320.[Medline]
- Nielsen JF, Stentoft J, Aunsholt NA. Haemoptysis caused by aneurysm of saphenous bypass graft to a coronary artery Scand J Thorac Cardiovasc Surg 1988;22:189-191.[Medline]
- Gruberg L, Satler LF, Pfister AJ, Monsein LH, Leon MB. A large coronary artery saphenous vein bypass graft aneurysm with a fistulacase report and review of the literature. Catheter Cardiovasc Interv 1999;48:214-216.[Medline]
- Williams ML, Rampersaud E, Wolfe WG. A man with saphenous vein graft aneurysms after bypass surgery Ann Thorac Surg 2004;77:1815-1817.[Abstract/Free Full Text]
- Bednarík J, Vondracek P, Dusek L, Moravcova E, Cundrle I. Risk factors for critical illness polyneuromyopathy J Neurol 2005;252:343-351.[Medline]
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Abstract
Introduction
