IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES Giant Saphenous Vein Coronary Artery Bypass Graft Aneurysm Ikrita K. Klair and Jaime Palomino Department of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, Louisiana
A 64-year-old woman presented with recent onset of hemoptysis and left chest pain. Past medical history included right breast cancer status post–mastectomy/chemotherapy/radiation (2006), coronary artery disease status post–coronary artery bypass graft (CABG) (1992), hypertension, and hyperlipidemia. Chest radiograph (Figures 1A and 1B) showed a large, well-defined mass anterior to the left hilum, left lower lobe (LLL) nodule, artifacts of bypass surgery, and an elevated left hemi-diaphragm. Computed tomographic imaging (Figures 1C and 1D) showed a giant coronary artery graft aneurysm 7.3 3 6.0 cm, lumen 4.5 3 3.2 cm, and a LLL nodule, 2.2 3 2.1 cm. The patient underwent LLL wedge biopsy, which showed Stage IA lung adenocarcinoma. The operation was complicated by myocardial infarction; left heart catheterization (Figure 1E and Video E1 in the online supplement) showed multiple aneurysmal dilatations of her saphenous vein graft (SVG) to the left anterior descending artery. She was offered surgery, but declined. Three months later, she came to the emergency room with chest pain and consented to outpatient surgery. A few days later (before surgical intervention could be done), she was brought to the emergency department with severe hemoptysis and was unresponsive at presentation. She was found to be in asystole and, despite all resuscitation efforts, she died in asystole. We suspect that SVG aneurysm rupture was the cause of her fatal presentation. The family declined autopsy. In a retrospective analysis of 5,579 CABG surgeries performed at a single center, the incidence of SVG aneurysms (SVGAs) was reported to be 0.07% (3). In a recent systematic review of published cases, it was noted that the most common clinical presentation of SVGAs is chest pain/angina (.40%), and only about 4% of patients presented with hemoptysis (1). The abnormality is initially observed by chest X-ray in over 50% of cases (2). SVGAs typically arise remotely from the initial bypass surgery, being identified an average of 13 years later after CABG (1). Complications of SVG aneurysms include sudden rupture (hemothorax, hemopericardium/ cardiac tamponade, sudden death, hematoma compressing adjacent structures), thrombus formation (embolization), compression and mass effect, fistula formation (isolated reports include fistula formation to right atrium, pulmonary artery, coronary sinus, anterior chest wall), and superior vena cava syndrome (from hematoma compression, or right atrium fistula). Traditionally, the management of SVGAs has been surgical—generally, resection of the aneurysm with or without bypass of the affected territory. However, with the refinement of percutaneous techniques, including the use of Amplatzer vascular plug devices, covered stents, and arterial coiling, the management options for affected patients are becoming increasingly diverse (1). n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Ramirez FD, Hibbert B, Simard T, Pourdjabbar A, Wilson KR, Hibbert R, Kazmi M, Hawken S, Ruel M, Labinaz M, et al. Natural history and management of aortocoronary saphenous vein graft aneurysms: a systematic review of published cases. Circulation 2012;126: 2248–2256.
2. Almanaseer Y, Rosman HS, Kazmouz G, Giraldo AA, Martin J. Severe dilatation of saphenous vein grafts: a late complication of coronary surgery in which the diagnosis is suggested by chest x-ray. Cardiology 2005;104:150–155. 3. Dieter RS, Patel AK, Yandow D, Pacanowski JP Jr, Bhattacharya A, Gimelli G, Kosolcharoen P, Russell D. Conservative vs. invasive treatment of aortocoronary saphenous vein graft aneurysms: treatment algorithm based upon a large series. Cardiovasc Surg 2003; 11:507–513.
Author Contributions: I.K.K. and J.P. participated equally in the preparation/drafting of the manuscript, both for the case description and for the intellectual component/published literature. This article has an online video supplement, which is accessible from this issue’s table of contents at www.atsjournals.org Am J Respir Crit Care Med Vol 189, Iss 5, pp e8–e9, Mar 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201304-0717IM Internet address: www.atsjournals.org
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
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4C/FPO
IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES
Figure 1. (A) Chest radiograph—posteroanterior view showing mass (white arrow) and left lower lobe (LLL) nodule (red arrow). (B) Chest radiograph— lateral view showing mass (white arrow) and LLL nodule (red arrow). (C) Computed tomography (CT) scan of the chest—axial reconstruction (white arrow, 7.3 3 6.0 cm saphenous vein coronary graft aneurysm; red arrow, ascending aorta). (D) CT scan of the chest—axial reconstruction (white arrow, LLL nodule). (E) Coronary angiogram (white arrows, saphenous vein coronary artery bypass graft aneurysms).
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American Journal of Respiratory and Critical Care Medicine Volume 189 Number 5 | March 1 2014
A 64-year-old woman presented with recent onset of hemoptysis and left chest pain. Past medical history included right breast cancer status post–mastectomy/chemotherapy/radiation (2006), coronary artery disease status post–coronary artery bypass graft (CABG) (1992), hypertension, and hyperlipidemia. Chest radiograph (Figures 1A and 1B) showed a large, well-defined mass anterior to the left hilum, left lower lobe (LLL) nodule, artifacts of bypass surgery, and an elevated left hemi-diaphragm. Computed tomographic imaging (Figures 1C and 1D) showed a giant coronary artery graft aneurysm 7.3 3 6.0 cm, lumen 4.5 3 3.2 cm, and a LLL nodule, 2.2 3 2.1 cm. The patient underwent LLL wedge biopsy, which showed Stage IA lung adenocarcinoma. The operation was complicated by myocardial infarction; left heart catheterization (Figure 1E and Video E1 in the online supplement) showed multiple aneurysmal dilatations of her saphenous vein graft (SVG) to the left anterior descending artery. She was offered surgery, but declined. Three months later, she came to the emergency room with chest pain and consented to outpatient surgery. A few days later (before surgical intervention could be done), she was brought to the emergency department with severe hemoptysis and was unresponsive at presentation. She was found to be in asystole and, despite all resuscitation efforts, she died in asystole. We suspect that SVG aneurysm rupture was the cause of her fatal presentation. The family declined autopsy. In a retrospective analysis of 5,579 CABG surgeries performed at a single center, the incidence of SVG aneurysms (SVGAs) was reported to be 0.07% (3). In a recent systematic review of published cases, it was noted that the most common clinical presentation of SVGAs is chest pain/angina (.40%), and only about 4% of patients presented with hemoptysis (1). The abnormality is initially observed by chest X-ray in over 50% of cases (2). SVGAs typically arise remotely from the initial bypass surgery, being identified an average of 13 years later after CABG (1). Complications of SVG aneurysms include sudden rupture (hemothorax, hemopericardium/ cardiac tamponade, sudden death, hematoma compressing adjacent structures), thrombus formation (embolization), compression and mass effect, fistula formation (isolated reports include fistula formation to right atrium, pulmonary artery, coronary sinus, anterior chest wall), and superior vena cava syndrome (from hematoma compression, or right atrium fistula). Traditionally, the management of SVGAs has been surgical—generally, resection of the aneurysm with or without bypass of the affected territory. However, with the refinement of percutaneous techniques, including the use of Amplatzer vascular plug devices, covered stents, and arterial coiling, the management options for affected patients are becoming increasingly diverse (1). n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Ramirez FD, Hibbert B, Simard T, Pourdjabbar A, Wilson KR, Hibbert R, Kazmi M, Hawken S, Ruel M, Labinaz M, et al. Natural history and management of aortocoronary saphenous vein graft aneurysms: a systematic review of published cases. Circulation 2012;126: 2248–2256.
2. Almanaseer Y, Rosman HS, Kazmouz G, Giraldo AA, Martin J. Severe dilatation of saphenous vein grafts: a late complication of coronary surgery in which the diagnosis is suggested by chest x-ray. Cardiology 2005;104:150–155. 3. Dieter RS, Patel AK, Yandow D, Pacanowski JP Jr, Bhattacharya A, Gimelli G, Kosolcharoen P, Russell D. Conservative vs. invasive treatment of aortocoronary saphenous vein graft aneurysms: treatment algorithm based upon a large series. Cardiovasc Surg 2003; 11:507–513.
Author Contributions: I.K.K. and J.P. participated equally in the preparation/drafting of the manuscript, both for the case description and for the intellectual component/published literature. This article has an online video supplement, which is accessible from this issue’s table of contents at www.atsjournals.org Am J Respir Crit Care Med Vol 189, Iss 5, pp e8–e9, Mar 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201304-0717IM Internet address: www.atsjournals.org
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
e8
4C/FPO
IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES
Figure 1. (A) Chest radiograph—posteroanterior view showing mass (white arrow) and left lower lobe (LLL) nodule (red arrow). (B) Chest radiograph— lateral view showing mass (white arrow) and LLL nodule (red arrow). (C) Computed tomography (CT) scan of the chest—axial reconstruction (white arrow, 7.3 3 6.0 cm saphenous vein coronary graft aneurysm; red arrow, ascending aorta). (D) CT scan of the chest—axial reconstruction (white arrow, LLL nodule). (E) Coronary angiogram (white arrows, saphenous vein coronary artery bypass graft aneurysms).
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American Journal of Respiratory and Critical Care Medicine Volume 189 Number 5 | March 1 2014
