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Ann Thorac Surg 2008;86:664. doi:10.1016/j.athoracsur.2007.10.006
© 2008 The Society of Thoracic Surgeons
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Images in Cardiothoracic Surgery

Spontaneous Coronary Bypass Rupture

Jan Kaehler, MDa,*, Olaf Franzen, MDa, Marc Regier, MDb, Joern Lorenzen, MDb, Thomas Meinertz, MDa, Hermann Reichenspurner, MD, PhDc, Christian Detter, MDc

a Department of Cardiology, University Hospital Hamburg, Hamburg, Germany
b Department of Radiology, University Hospital Hamburg, Hamburg, Germany
c Department of Thoracic and Cardiovascular Surgery, University Hospital Hamburg, Hamburg, Germany

* Address correspondence to Dr Kaehler, University Hospital Hamburg, Department of Cardiology, Martinistrassse 52, Hamburg, 22299, Germany (Email: kaehler{at}uke.uni-hamburg.de).

A 71-year-old man was admitted for atypical chest pain and acute myocardial infarction was ruled out. Past medical history included coronary three-vessel-disease, coronary artery bypass grafting (CABG), and subsequent implantation of seven coronary stents. The CABG was performed 21 years ago with saphenous vein grafting (SVG) to the left anterior descending coronary artery (LAD), the obtuse marginal branch (OM), and the right coronary artery (RCA). Eight years and 6 months ago, respectively, stents were implanted into the middle and distal part of the SVG supplying the RCA.

Bilateral pneumonia was treated for 8 days and the symptoms ceased. However, because the patient's leucocytes and C-reactive protein remained elevated, a chest computed tomography was performed and the scan revealed a retrosternal mass 7 cm in diameter (Fig 1, arrow; LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle). A coronary angiography revealed a massive leakage of contrast dye in the mid portion of the SVG to the RCA (Fig 2, arrow).


Figure 1
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  		Fig 1.
 

Figure 2
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  		Fig 2.
 
After balloon occlusion of the proximal segment of the SVG with an angioplasty balloon catheter, the patient was immediately transferred to the operating room. After installation of a femoro-femoral cardiopulmonary bypass, a redo sternotomy was performed in deep hypothermia. Surgical exploration revealed massive intrathoracic bleeding and a large retrosternal, partially organized hematoma. The SVG to the RCA was found to be completely ruptured 6 cm distal to the aortal anastomosis and it was ligated after removal of the hematoma (Fig 3, arrows). Redo triple coronary artery bypass grafting was performed using SVG to the posterior descending branch of the RCA and the OM, and an internal mammary artery to the LAD. The patient was successfully weaned from the extracorporeal circulation and recovered within 9 days.


Figure 3
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  		Fig 3.
 
Mechanical degeneration of saphenous vein bypass grafts is a well-known entity, usually manifesting in the development of bypass aneurysms [1], whereas bypass rupture is an extremely rare event [2]. Due to extensive retrosternal adhesions in our patient, bleeding was limited and resulted in the development of a large perfused hematoma.


   References
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 References
 

  1. Mohara J, Konishi H, Kato M, Misawa Y, Kamisawa O, Fuse K. Saphenous vein graft pseudoaneurysm rupture after coronary artery bypass grafting Ann Thorac Surg 1998;65:831-832.[Abstract/Free Full Text]
  2. Steg PG, Benacerraf M, Chatel D, Laissy JP. Images in cardiovascular medicine. False aortic aneurysm due to rupture of an aortocoronary saphenous vein bypass graft. Circulation 1997;96:3778.[Free Full Text]




This Article
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