International Journal of Cardiology 182 (2015) 384–386
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Giant saphenous vein graft aneurysm: A complex multi-disciplinary percutaneous approach Vincenzo Vizzi a,⁎, Chiara Bucciarelli-Ducci a, Thomas W. Johnson a, Nathan E. Manghat a, Andreas Baumbach a, Simon Walsh b, Mark S. Turner a, James C. Spratt c, Julian W. Strange a a b c
Department of Cardiology, Bristol Heart Institute, Bristol, England, United Kingdom Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom Edinburgh Heart Centre, Little France, Edinburgh, Scotland, United Kingdom
a r t i c l e
i n f o
Article history: Received 20 December 2014 Accepted 31 December 2014 Available online 4 January 2015 Keywords: Coronary Chronic Total Occlusion Cardiac Magnetic Resonance Saphenous Vein Graft Aneurysm
A 75-year old hypertensive, type II diabetic gentleman presented with an episode of cardiac sounding chest pain, without ischemic ECG changes or troponin rise. His previous cardiac history included coronary artery bypass grafting (CABG) in 1991 for stable angina, with a left internal mammary artery to left anterior descending artery and saphenous vein grafts (SVGs) to right coronary artery (RCA) and first diagonal branch. He was under regular cardiac review following treatment of an aneurysmal segment of his SVG to the RCA in 2008 with two Graftmaster® covered stents (Abbott Vascular Inc., Illinois, USA). He required repeat percutaneous coronary intervention (PCI) with the implantation of two further Graftmaster® covered stents in 2010, following detection of enlargement of the original aneurysmal segment and evidence of a leak at the point of overlap of the original stents by computed tomography. A repeat angiogram demonstrated no clear target for intervention, with excellent patency of all the grafts, including the SVG to the RCA. The native LAD and the RCA were both occluded proximally and the circumflex artery was severely diseased and recessive. A stress perfusion magnetic resonance scan (MRI) was requested to rule out major territory ischaemia. This scan provided useful information in demonstrating viability in all territories, no inducible ischaemia and ⁎ Corresponding author at: Bristol Heart Institute, Upper Maudlin Street, BS2 8HW, Bristol, United Kingdom. E-mail address: [email protected] (V. Vizzi).
http://dx.doi.org/10.1016/j.ijcard.2014.12.168 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
only mild impairment of the left ventricular systolic function. Additionally, despite two previous interventions with covered stents, comparison with previous CT imaging confirmed a further increase in the SVG aneurysm dimensions (from 36 mm to 40 mm maximum), with partial compression of the superior vena cava and the right atrium (Fig. 1). The case was discussed at a multi-disciplinary team meeting, attended by cardiac surgeons, cardiologists and anaesthetists, and a repeat CABG operation for the right coronary artery was ruled out as an option: the patient's EUROSCORE II was 10.2%, the risk of damage to the patent LIMA was deemed high and the presence of chronic venous insufficiency made harvesting of new conduits challenging. Consequently, a percutaneous strategy was proposed to deal with the expanding aneurysmal vein graft. Firstly, the patient underwent a PCI to the chronically occluded native right coronary artery. Using the aneurysmal vein graft as a conduit for retrograde access to the distal RCA, reverse-CART (Controlled Antegrade and Retrograde subintimal Tracking) was performed and three Promus Premier® (Boston Scientific Corporation, Massachusetts, USA) stents were successfully implanted in the vessel. There was an excellent final result and TIMI 3 distal flow (Fig. 2, panels A–C). The procedure took 90 min, with the use of 300 ml of nonionic monomer low-osmolar contrast medium (Iomeron 300®, Bracco Ltd., UK). The patient was discharged the following day without complications. In a second staged procedure, two 8 mm Amplatzer™ Vascular Plug 4 (St. Jude Medical Inc., Minnesota, USA) were inserted in the proximal and distal SVG, with minimal contrast flowing through the devices and a final TIMI 1 flow (Fig. 2, panels D and E). The procedure was performed as day-case procedure and the patient was discharged after 8 h of observation without complications. A CT scan performed one month later confirmed the successful complete occlusion of the vein graft (Fig. 2, panel F) and the patient's clinical follow-up at 3 months was unremarkable. Saphenous vein graft aneurysm is extensively described in literature and is one of the late possible complications of CABG. The aetiology is unclear and the clinical presentation varies. There is no clear consensus regarding the best treatment option despite the potentially fatal consequence of aneurysmal rupture. In a published review of case reports [1], Ramirez FD et al. have proposed a treatment algorithm where two main percutaneous strategies are included: the exclusion of the aneurysm
V. Vizzi et al. / International Journal of Cardiology 182 (2015) 384–386
385
Fig. 1. Cardiac magnetic resonance. Panels A and B. Cardiac magnetic resonance, late myocardial enhancement basal short-axis (A) and 2-chamber view long-axis views (B) acquired 15 min after contrast injection. The images demonstrate complete myocardial viability of all myocardial segments, including the inferior wall (white arrows). Panels C and D. The cardiac magnetic resonance also demonstrated increased dimension of the aneurysm, in comparison with the previous CT follow-up scan (white stars). The aneurysm caused initial compression of the superior vena cava (panel C, yellow arrowhead) and to the right atrium (panel D, yellow arrowhead). LV: left ventricle, RV: right ventricle, Ao: ascending aorta, and LA: left atrium.
Fig. 2. Percutaneous treatment of the saphenous vein graft. Panel A. Coronary angiogram showing chronic total occlusion of the proximal right coronary artery (RCA). Panel B. PCI to the RCA using the reverse CART (Controlled Antegrade and Retrograde subintimal Tracking) technique, with the vein graft as retrograde conduit. Panel C. Final angiographic result of the CTO PCI, with excellent patency of the native right coronary artery. Panels D and E. Percutaneous occlusion of the vein graft with two Amplatzer™ Vascular Plugs (black arrows), one in the distal graft (panel E) and one in the proximal graft (panel D). Panel F. CT follow-up scan after 3 months showing complete occlusion of the vein graft (yellow arrows showing the vascular plugs previously inserted). Ao: ascending aorta and LV: left ventricle.
386
V. Vizzi et al. / International Journal of Cardiology 182 (2015) 384–386
with covered stents or its occlusion (with plug devices or coil) if the supplied myocardial territory is small or non viable. If the aneurysmal graft is unsuitable for delivery of covered stents or a significant territory of viable myocardium is in jeopardy, the surgical option is suggested. Our clinical case demonstrates a novel percutaneous strategy for treatment. Despite previous failure of PCI to exclude the aneurysm with covered stents and a large territory of viable myocardium at risk, we have avoided a re-do surgical operation in a high risk patient. Although cases utilising saphenous vein grafts as a retrograde access route for a CTO angioplasty to the native coronary artery have been reported [2], to our knowledge, this is the first case in the literature adopting a staged percutaneous strategy to treat an aneurysmal vein graft, by firstly disobliterating a native coronary artery CTO via the diseased SVG and then, occluding the SVG with the Amplatzer™ Plug Device. The history of repeated failure of the covered stents is hard to explain. In our case the patient underwent two years after the first PCI a re-do procedure with a repeat covered stent insertion due to a new leaking demonstrated with the CT. After two more years, we have demonstrated increased aneurysm dimensions despite its successful exclusion with the covered stents. Authors have proposed the late
malapposition of the covered stents as possible cause, but more data are required to corroborate this hypothesis [3]. Finally, our case highlights the importance of a multi-disciplinary approach. Interventional cardiologists, cardiac surgeons and radiologists need to cooperate as a “heart team” to plan and enact a customised patient-tailored therapy. Conflicts of interest The authors report no relationships that could be construed as a conflict of interest. References [1] F.D. Ramirez, B. Hibbert, T. Simard, et al., Natural history and management of aortocoronary saphenous vein graft aneurysms: a systematic review of published cases, Circulation 126 (2012) 2248–2256. [2] P.C. Ho, E. Tsuchikane, Improvement of regional ischemia after successful percutaneous intervention of bypassed native coronary chronic total occlusion: an application of the CART technique, J. Invasive Cardiol. 20 (2008) 305–308. [3] T.J. Glenie, S.S. El-Jack, Repeat percutaneous treatment of a large vein graft aneurysm with covered stents, Heart Lung Circ. 21 (2012) 305–306.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Giant saphenous vein graft aneurysm: A complex multi-disciplinary percutaneous approach Vincenzo Vizzi a,⁎, Chiara Bucciarelli-Ducci a, Thomas W. Johnson a, Nathan E. Manghat a, Andreas Baumbach a, Simon Walsh b, Mark S. Turner a, James C. Spratt c, Julian W. Strange a a b c
Department of Cardiology, Bristol Heart Institute, Bristol, England, United Kingdom Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom Edinburgh Heart Centre, Little France, Edinburgh, Scotland, United Kingdom
a r t i c l e
i n f o
Article history: Received 20 December 2014 Accepted 31 December 2014 Available online 4 January 2015 Keywords: Coronary Chronic Total Occlusion Cardiac Magnetic Resonance Saphenous Vein Graft Aneurysm
A 75-year old hypertensive, type II diabetic gentleman presented with an episode of cardiac sounding chest pain, without ischemic ECG changes or troponin rise. His previous cardiac history included coronary artery bypass grafting (CABG) in 1991 for stable angina, with a left internal mammary artery to left anterior descending artery and saphenous vein grafts (SVGs) to right coronary artery (RCA) and first diagonal branch. He was under regular cardiac review following treatment of an aneurysmal segment of his SVG to the RCA in 2008 with two Graftmaster® covered stents (Abbott Vascular Inc., Illinois, USA). He required repeat percutaneous coronary intervention (PCI) with the implantation of two further Graftmaster® covered stents in 2010, following detection of enlargement of the original aneurysmal segment and evidence of a leak at the point of overlap of the original stents by computed tomography. A repeat angiogram demonstrated no clear target for intervention, with excellent patency of all the grafts, including the SVG to the RCA. The native LAD and the RCA were both occluded proximally and the circumflex artery was severely diseased and recessive. A stress perfusion magnetic resonance scan (MRI) was requested to rule out major territory ischaemia. This scan provided useful information in demonstrating viability in all territories, no inducible ischaemia and ⁎ Corresponding author at: Bristol Heart Institute, Upper Maudlin Street, BS2 8HW, Bristol, United Kingdom. E-mail address: [email protected] (V. Vizzi).
http://dx.doi.org/10.1016/j.ijcard.2014.12.168 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
only mild impairment of the left ventricular systolic function. Additionally, despite two previous interventions with covered stents, comparison with previous CT imaging confirmed a further increase in the SVG aneurysm dimensions (from 36 mm to 40 mm maximum), with partial compression of the superior vena cava and the right atrium (Fig. 1). The case was discussed at a multi-disciplinary team meeting, attended by cardiac surgeons, cardiologists and anaesthetists, and a repeat CABG operation for the right coronary artery was ruled out as an option: the patient's EUROSCORE II was 10.2%, the risk of damage to the patent LIMA was deemed high and the presence of chronic venous insufficiency made harvesting of new conduits challenging. Consequently, a percutaneous strategy was proposed to deal with the expanding aneurysmal vein graft. Firstly, the patient underwent a PCI to the chronically occluded native right coronary artery. Using the aneurysmal vein graft as a conduit for retrograde access to the distal RCA, reverse-CART (Controlled Antegrade and Retrograde subintimal Tracking) was performed and three Promus Premier® (Boston Scientific Corporation, Massachusetts, USA) stents were successfully implanted in the vessel. There was an excellent final result and TIMI 3 distal flow (Fig. 2, panels A–C). The procedure took 90 min, with the use of 300 ml of nonionic monomer low-osmolar contrast medium (Iomeron 300®, Bracco Ltd., UK). The patient was discharged the following day without complications. In a second staged procedure, two 8 mm Amplatzer™ Vascular Plug 4 (St. Jude Medical Inc., Minnesota, USA) were inserted in the proximal and distal SVG, with minimal contrast flowing through the devices and a final TIMI 1 flow (Fig. 2, panels D and E). The procedure was performed as day-case procedure and the patient was discharged after 8 h of observation without complications. A CT scan performed one month later confirmed the successful complete occlusion of the vein graft (Fig. 2, panel F) and the patient's clinical follow-up at 3 months was unremarkable. Saphenous vein graft aneurysm is extensively described in literature and is one of the late possible complications of CABG. The aetiology is unclear and the clinical presentation varies. There is no clear consensus regarding the best treatment option despite the potentially fatal consequence of aneurysmal rupture. In a published review of case reports [1], Ramirez FD et al. have proposed a treatment algorithm where two main percutaneous strategies are included: the exclusion of the aneurysm
V. Vizzi et al. / International Journal of Cardiology 182 (2015) 384–386
385
Fig. 1. Cardiac magnetic resonance. Panels A and B. Cardiac magnetic resonance, late myocardial enhancement basal short-axis (A) and 2-chamber view long-axis views (B) acquired 15 min after contrast injection. The images demonstrate complete myocardial viability of all myocardial segments, including the inferior wall (white arrows). Panels C and D. The cardiac magnetic resonance also demonstrated increased dimension of the aneurysm, in comparison with the previous CT follow-up scan (white stars). The aneurysm caused initial compression of the superior vena cava (panel C, yellow arrowhead) and to the right atrium (panel D, yellow arrowhead). LV: left ventricle, RV: right ventricle, Ao: ascending aorta, and LA: left atrium.
Fig. 2. Percutaneous treatment of the saphenous vein graft. Panel A. Coronary angiogram showing chronic total occlusion of the proximal right coronary artery (RCA). Panel B. PCI to the RCA using the reverse CART (Controlled Antegrade and Retrograde subintimal Tracking) technique, with the vein graft as retrograde conduit. Panel C. Final angiographic result of the CTO PCI, with excellent patency of the native right coronary artery. Panels D and E. Percutaneous occlusion of the vein graft with two Amplatzer™ Vascular Plugs (black arrows), one in the distal graft (panel E) and one in the proximal graft (panel D). Panel F. CT follow-up scan after 3 months showing complete occlusion of the vein graft (yellow arrows showing the vascular plugs previously inserted). Ao: ascending aorta and LV: left ventricle.
386
V. Vizzi et al. / International Journal of Cardiology 182 (2015) 384–386
with covered stents or its occlusion (with plug devices or coil) if the supplied myocardial territory is small or non viable. If the aneurysmal graft is unsuitable for delivery of covered stents or a significant territory of viable myocardium is in jeopardy, the surgical option is suggested. Our clinical case demonstrates a novel percutaneous strategy for treatment. Despite previous failure of PCI to exclude the aneurysm with covered stents and a large territory of viable myocardium at risk, we have avoided a re-do surgical operation in a high risk patient. Although cases utilising saphenous vein grafts as a retrograde access route for a CTO angioplasty to the native coronary artery have been reported [2], to our knowledge, this is the first case in the literature adopting a staged percutaneous strategy to treat an aneurysmal vein graft, by firstly disobliterating a native coronary artery CTO via the diseased SVG and then, occluding the SVG with the Amplatzer™ Plug Device. The history of repeated failure of the covered stents is hard to explain. In our case the patient underwent two years after the first PCI a re-do procedure with a repeat covered stent insertion due to a new leaking demonstrated with the CT. After two more years, we have demonstrated increased aneurysm dimensions despite its successful exclusion with the covered stents. Authors have proposed the late
malapposition of the covered stents as possible cause, but more data are required to corroborate this hypothesis [3]. Finally, our case highlights the importance of a multi-disciplinary approach. Interventional cardiologists, cardiac surgeons and radiologists need to cooperate as a “heart team” to plan and enact a customised patient-tailored therapy. Conflicts of interest The authors report no relationships that could be construed as a conflict of interest. References [1] F.D. Ramirez, B. Hibbert, T. Simard, et al., Natural history and management of aortocoronary saphenous vein graft aneurysms: a systematic review of published cases, Circulation 126 (2012) 2248–2256. [2] P.C. Ho, E. Tsuchikane, Improvement of regional ischemia after successful percutaneous intervention of bypassed native coronary chronic total occlusion: an application of the CART technique, J. Invasive Cardiol. 20 (2008) 305–308. [3] T.J. Glenie, S.S. El-Jack, Repeat percutaneous treatment of a large vein graft aneurysm with covered stents, Heart Lung Circ. 21 (2012) 305–306.
