Saphenous vein graft aneurysm (SVGA) is one of the chronic complications after coronary artery bypass graft (CABG) surgery [1,2]. However, a serially-observed case of giant saphenous vein graft aneurysm after coronary artery bypass surgery is rare.
We describe a case of a large, growing SVGA that was followed by chest radiography (Figure 1) and computed tomography (CT) (Figure 2). The SVGA was ultimately resected without bypass via off-pump surgery.
2 Case report
We present a case of 70-year-old man who underwent coronary arteriography first at 48 years of age that revealed severe triple-vessel disease. Hence, CABG of the left internal thoracic artery to left anterior descending artery and of the aorta to the right coronary artery (RCA) (the 4AV branch via the SVG) were performed.
Eighteen years later, a vein graft aneurysm (23 × 24 mm) was incidentally detected where the SVG was anastomosed to the RCA (Figures 1a and 2a). The patient was asymptomatic and was followed conservatively. Several months later, he experienced acute coronary syndrome (ACS) and underwent emergency coronary arteriography. The surgery revealed that RCA and the SVG to the RCA were totally occluded with a giant graft aneurysm (Figure 3). Percutaneous coronary intervention was unsuccessful; therefore, conservative medical treatment was administered.
Four years later, echocardiography revealed a giant mass in the right atrium. Coronary CT angiography showed that the giant aneurysm had grown to 52.1 by 63.8 mm and revealed a second, smaller aneurysm (Figures 2b, 4). Blood flowed lightly through the small lumen of the large aneurysm.
Ethical approval: The research related to human use has complied with all the relevant national regulations and institutional policies in accordance with the tenets of the Helsinki Declaration and has been approved by the authors’ institutional review board (or equivalent) committee.
Informed consent has been obtained from all individuals included in this study.
Saphenous vein graft aneurysms are rare and may be caused by atherosclerosis-like phenomena of the vein graft, weakness around the vein valve, rupturing of the suture of the graft anastomosis, or perioperative graft injury [3,4]. The cause in our case was unclear.
If the diameter of an aneurysm is less than 1 cm with adequate blood flow, medically conservative treatment is commonly indicated, with the international normalized ratio maintained at 2 to 2.5 to prevent emboli. Magnetic resonance imaging and/or CT should be required during follow-up . If the aneurysm’s diameter is 2 cm or more, or is rapidly expanding, surgical intervention is recommended .
Some reports suggest that coil embolization or mildly invasive catheter intervention with the closure device (Amplatzer vascular plug®, Amplatzer Vascular Plug II®) can substitute for surgical treatment [7-10]. However, the success rate of the catheter intervention is not very high. It has been reported that the vein graft aneurysm is considered to be an indication for surgical treatment when the diameter of the aneurysm is more than 20 mm . In our case, the graft aneurysm was more than 20 mm before the ACS developed, hence, the requirement for surgery.
The optimal management of this rare complication is not well established. The recommendation for management is as stated in our case report, rather than recommended by evidence-based practice or consensus statement.
In summary, this case suggested that aggressive treatment that includes surgical intervention should be considered before the aneurysm becomes larger, even if it is asymptomatic.
Conflict of interest statement: Authors state no conflict of interest.
Kazui T, Harada H, Komatsu S: Saphenous vein aneurysm following coronary artery bypass grafting. J Cardiovasc Surg (Torino) 1988; 29: 364-367 Google Scholar
Sareyyupoglu B, Schaff HV, Ucar I, et al.: Surgical treatment of saphenous vein graft aneurysms after coronary artery revascularization. Ann Thorac Surg 2009; 88: 1801-1805 Google Scholar
Dabboussi M, Saade YA, Poncet A, Baehrel B: Fistula between a saphenous vein graft aneurysm and the pulmonary artery trunk. Ann Thorac Surg 2001; 71:1356-1358 Google Scholar
Benchimol A, Harris CL, Desser KB, Fleming H: Aneurysm of an aorto-coronary artery saphenous vein bypass graft–a case report. Vasc Surg 1975; 9: 261-264 Google Scholar
Rana O, Greaves K, Shepherd D, Parvin S, Swallow R: Saphenous vein graft aneurysm: an incidental finding. BMJ Case Rep 2009; pii: bcr07.2008.0455 Google Scholar
Nishimura K, Nakamura Y, Harada S, et al.: Saphenous vein graft aneurysm after coronary artery bypass grafting. Ann Thorac Cardiovasc Surg 2009; 15: 61-63 Google Scholar
Dimitri WR, Reid AW, Dunn FG: Leaking false aneurysm of right coronary saphenous vein graft; successful treatment by percutaneous coil embolization. Br Heart J 1992; 68:619 Google Scholar
Katoh H, Nozue T, Michishita I: A case of giant saphenous vein graft aneurysm successfully treated with catheter intervention. Catheter Cardiovasc Interv. 2015 May 26; doi: 10.1002/ccd.25984. [Epub ahead of print]CrossrefGoogle Scholar
Kim D, Guthaner DF, Wexler L: Transcatheter embolization of a leaking pseudoaneurysm of saphenous vein aortocoronary bypass graft. Cathet Cardiovasc Diagn 1983; 9: 591-594Google Scholar
Ayub B, Martinez MW, Jaffe AS, Couri DM: Giant saphenous vein graft pseudoaneurysm: treatment with a vascular occlusion device. Interact Cardiovasc Thorac Surg. 2012;15(1):164-165 Google Scholar
Memon AQ, Huang RI, Marcus F et al.: Saphenous vein graft aneurysm: case report and review. Cardiol Res 2003; 11: 26-34 Google Scholar
About the article
Published Online: 2016-05-25
Published in Print: 2016-01-01
Citation Information: Open Medicine, Volume 11, Issue 1, Pages 155–157, ISSN (Online) 2391-5463, DOI: https://doi.org/10.1515/med-2016-0030.
© 2016 Tadateru Takayama et al.. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License. BY-NC-ND 3.0