Ann Thorac Surg 2006;82:742-744
© 2006 The Society of Thoracic Surgeons
Case report
Right Gastroepiploic Artery Grafting for Saphenous Vein Graft Pseudoaneurysm
Taketomo Mizukami, MDa,*,
Taijiro Sueda, MD, PhDb,
Hideichi Wada, MD, PhDa,
Katsuhiko Imai, MD, PhDb,
Masaki Hamamoto, MD, PhDb,
Daisuke Futagami, MDb
a Department of Cardiovascular Surgery, Onomichi General Hospital, Hiroshima, Japan
b Department of Surgery, Graduate School of Biochemical Science, Hiroshima University, Hiroshima, Japan
Accepted for publication November 7, 2005.
* Address correspondence to Dr Mizukami, Department of Cardiovascular Surgery, Onomichi General Hospital, 7-19 Kohama-cho, Onomichi City, Hiroshima, 722-8508 Japan (Email: qqen4nx9{at}violin.ocn.ne.jp).
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Abstract
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Saphenous vein graft pseudoaneurysms are an unusual but potentially fatal complication of coronary artery bypass grafting because of their high risk of rupture or thromboembolism. We experienced the case of a 58-year-old man with a saphenous vein graft pseudoaneurysm with a floating thrombus that had developed 17 years after the initial coronary artery bypass grafting. The prevention of thromboembolism during a surgical procedure has been crucial for this type of operation. We developed the idea of in situ revascularization using the right gastroepiploic artery under the beating heart on cardiopulmonary bypass followed by an aneurysmectomy under an arrested heart.
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Introduction
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Pseudoaneurysms of saphenous vein grafts (SVGs) are a rare complication of coronary artery bypass grafting (CABG), and there are several risks such as rupture and thromboembolism. Therefore, the strategy of the treatment is generally surgery [1]. Here we report the case of an SVG pseudoaneurysm accompanied by a floating thrombus that developed 17 years after the initial CABG.
The patient was a 54-year-old man who underwent a CABG in 1987. Aortocoronary anastomoses with SVGs were applied to the left anterior descending artery and right coronary artery (RCA) (segment no. 3). The postoperative course was uneventful, and the patient had been free from anginal symptoms until the onset of anterior chest pain in September 2004. A computed tomographic scan of the chest revealed a large mediastinal mass (28 x 16 mm in diameter) with a floating thrombus. A cardiac catheterization revealed an aneurysmal dilatation on the proximal part of the SVG to the RCA, which delayed filling of the contrast medium in the RCA caused by the partial obstruction with a floating thrombus (Fig 1).
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Fig 1. Coronary angiogram shows an aneurysmal dilatation on the proximal side of the saphenous vein graft to the right coronary artery (RCA); there is delayed filling of the RCA due to mural thrombus (arrow).
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The patient underwent reoperation in October 2004. After establishing a cardiopulmonary bypass with a return cannula into the femoral artery and a drainage cannula into the right atrium through the femoral vein, we first performed bypass grafting to the RCA under the beating heart. The in situ right gastroepiploic artery (RGEA) was anastomosed to the RCA (segment no. 4). The RCA was clamped between the two anastomoses of the SVG and RGEA to reduce the prevalence of embolization into the distal RCA prior to the antegrade cardioplegia perfusion. After that, cardiac arrest was obtained. The aneurysmal SVG was dissected and longitudinally incised. The aneurysm was filled with a fresh and organized thrombus. Surprisingly when the thrombus was removed, a graft marker used in the initial operation was found in the aneurysm. This finding suggested that the dilated SVG was a pseudoaneurysm caused by a disruption of the proximal anastomosis (Fig 2). We carefully dissected the distal anastomosis of the aneurysmal graft to prevent dislodgement of the thrombus, and we totally resected the aneurysmal SVG. Weaning from cardiopulmonary bypass was easily achieved with the support of low-dose dopamine. The postoperative course was uneventful; cardiac catheterization demonstrated patency of the RGEA graft with no thrombus in the RCA.
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Fig 2. Intraoperative photograph of redo CABG revealing local extent of pseudoaneurysm (dotted line). (RCA = right coronary artery; RGEA = right gastroepiploic artery; SVG = saphenous vein graft.)
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Comment
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The treatment of SVG aneurysms is controversial. Dieter and colleagues [2] reported that early surgical treatment of SVG aneurysms did not prolong the survival as compared with that of conservative management. On the other hand, Williams and associates [1] recommended the surgical exclusion of the aneurysm concomitant with the revascularization to the distal coronary artery irrespective of the patient's conditions, because untreated aneurysms may cause myocardial infarction or rupture. In our case, the floating thrombus seemed to easily embolize into the distal coronary circulation, and the patient's condition was good enough for him to be operated on. Therefore we planned a reoperative CABG.
The issues that occur in this kind of operation are the optimal conduit for the re-revascularization of the RCA and intraoperative prevention of a thromboembolism caused by the floating thrombus within the pseudoaneurysm. In the redo CABG, the conduits for the RCA included the RGEA and SVG. Some authors have reported that the coronary competitive flow and insufficient flow capacity limited the use of the RGEA when grafted to the RCA with a moderate stenosis [3, 4]. Shah and colleagues [5] showed that one of the operative variables associated with a reduced SVG patency was the coronary artery grafted to the RCA. In our case, we selected the RGEA rather than the SVG for several reasons: (1) the in situ grafting under the beating heart was feasible without touching the aorta, (2) the RCA had a severe stenosis of nearly 99%, (3) the duration of the cardiac arrest could be shortened, and (4) the patient had an episode of a vein graft disease and the RGEA thus had a potentially longer life expectancy. After the RCA bypass grafting, a pseudo-aneurysmectomy was attempted with special care so as not to create a thromboembolism of the floating thrombus. The dissection around the aneurysm under the beating state and antegrade administration of cardioplegia had higher risks of thromboembolism. Retrograde cardioplegia was an alternative, but was not applied in our case because of a tight adhesion around the heart. Therefore we clamped the RCA directly between the segment of the SVG anastomosis and RGEA anastomosis, infused cardioplegia antegradely, and obtained cardiac arrest. Under cardiac arrest, we successfully removed the pseudoaneurysm without any thromboembolism.
In summary, for the patients with SVG pseudoaneurysms related to a CABG, the surgical exclusion of the pseudoaneurysm and re-CABG were a useful option for the treatment of this fatal complication. We performed the re-revascularization of the RCA first under the beating heart with an in situ RGEA graft followed by a pseudo-aneurysmectomy under the arrested heart. There were no complications such as thromboembolism or perioperative myocardial infarction associated with this procedure.
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References
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- 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]
- Dieter RS, Patel AK, Yandow D, et al. Conservative vs invasive treatment of aortocoronary saphenous vein graft aneurysmstreatment algorithm based upon a large series. Cardiovasc Surg 2003;11:507-513.[Medline]
- Voutilainen S, Verkkala K, Jarvinen A, et al. Angiographic 5-year follow-up study of right gastroepiploic artery grafts Ann Thorac Surg 1996;62:501-505.[Abstract/Free Full Text]
- Ochi M, Hatori N, Fuji M, et al. Limited flow capacity of the right gastroepiploic artery graftpostoperative echocardiographic and angiographic evaluation. Ann Thorac Surg 2001;71:1210-1214.[Abstract/Free Full Text]
- Shah PJ, Gordon I, Fuller J, et al. Factors affecting saphenous vein graft patencyclinical and angiographic study in 1402 symptomatic patients operated on between 1977 and 1999. J Thorac Cardiovasc Surg 2003;126:1972-1977.[Abstract/Free Full Text]
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Abstract
Introduction
