© 2014 Wiley Periodicals, Inc.
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REVIEW ARTICLE _______________________________________________________________
Saphenous Venous Graft Pseudoaneurysm: A Review of the Literature Aiman Smer, M.D., Venkata Alla, M.D., Satish Chandraprakasam, M.D., Ahmed Abuzaid, M.D., Alok Saurav, M.D., and Jeffery Holmberg, M.D., Ph.D. Cardiology Department, Creighton University Medical Center, Omaha, Nebraska ABSTRACT Saphenous vein graft (SVG) pseudoaneurysm is a rare complication of coronary artery bypass graft (CABG) surgery. A review of literature indicates that almost one third of patients are asymptomatic at detection and a history of operative complications and need for re-exploration after the initial surgery may serve as useful predictors for the development of this rare complication. doi: 10.1111/jocs.12469 (J Card
Surg 2015;30:70–73) Saphenous vein graft (SVG) pseudoaneurysm is a rare and serious complication of coronary artery bypass (CABG) surgery.1 The presentation can vary from an incidental finding on an imaging study to a life-threatening emergency. We report two cases of SVG pseudoaneurysm that reflect the extreme variation in presentation and natural history, and highlight the need for tailored management. In addition, we performed a systematic review of published cases to identify presenting features and predictors of this rare complication. PATIENT PROFILES Both patients have agreed and signed an agreement form to publish their cases Case 1 A 91-year-old female with advanced dementia, hypertension, and three-vessel CABG in 1990 presented for evaluation of an incidental mediastinal mass on chest X-ray (Fig. 1), after a fall. Precordial exam revealed a grade III/VI continuous murmur at the right sternal border. Transthoracic echocardiogram (TTE) showed a large 8 cm 7 cm mass compressing the right ventricular outflow tract (Fig. 2) with evidence of continuous flow into it on color Doppler (Video 1) and contrast administration (Video 2). A chest computed tomography (CT) showed a large pseudoaneurysm
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Aiman Smer, M.D., 3006 Webster St, Omaha, NE 68131. Fax: þ1-402-4494140; e-mail: [email protected]
originating from the diagonal CABG (Fig. 3). Review of the operative records revealed that the surgical course was complicated by hemothorax requiring re-exploration of the chest. Intraoperatively oozing around the proximal anastomosis of the SVG to the diagonal branch was repaired. She remained asymptomatic until this admission. Considering her asymptomatic status, advanced age, dementia, and high risk for operative complications the family elected for a conservative approach without intervention. She remained asymptomatic at three months follow-up visit. Case 2 An 80-year-old male with multiple comorbidities presented with chest pain and dyspnea two weeks after cardiac surgery involving aortic valve replacement, mitral valve repair, and two-vessel CABG. The patient was in acute distress. He was noted to have peripheral edema, jugular venous distension, and bibasilar crackles. TTE showed a large echo dense mass in the anterior pericardial space consistent with a thrombus (Fig. 4). A CT angiogram (CTA) of the chest revealed 4 cm 3 cm pseudoaneurysm of the right CABG and a large pericardial hematoma 11 cm 7 cm with mass effect on the right ventricle and atrium (Fig. 5). Review of operative records indicated that his postoperative course was complicated by bleeding requiring re-exploration. Given his hemodynamic instability, he underwent emergent surgery with hematoma evacuation and repair of the SVG pseudoaneurysm. At the time of surgery, there was a large pseudoaneurysmal cavity communicating with the RCA graft proximal anastomosis to the ascending aorta via a small defect measuring
J CARD SURG 2015;30:70–73
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Figure 1. Chest X-ray antero-posterior supine view demonstrating a large mediastinal mass (arrows).
Figure 3. Computed tomography (CT) of the chest showing the pseudoaneurysm originating from the diagonal coronary artery bypass graft (arrow). AA, ascending aorta; PA, pulmonary artery.
6 to 8 mm at the site of suture dehiscence. The pseudoaneurysm was resected and the defect sutured. The postoperative course was uneventful. A followup visit at 18 months indicates he has been doing well.
surgery and presentation and importantly predictors of this important and potentially fatal complication. A comprehensive search of PubMed and Medline database, using the terms ‘‘pseudoaneurysm, aneurysm, SVG, and CABG,’’ revealed a total of 296 citations. After eliminating duplicate, non-English and true aneurysms articles, we identified 72 reports of SVG pseudoaneurysm. A detailed document of published case reports is available in the supplementary appendix. As illustrated in Table 1, the right CABG is the most commonly affected graft (47%), followed by left circumflex (29%), and left anterior descending arteries (20%). Interestingly, we found that 22% of all patients with this complication had needed surgical re-exploration postoperatively as compared to the Society of Thoracic Surgeons (STS) reported re-exploration rate of 3.1% in all comers undergoing CABG.5 A prior history of operative complications and need for reexploration following the initial surgery may serve as useful clues and a screening imaging study may be warranted in such patients for early diagnosis of SVG pseudoaneurysm.
DISCUSSION A pseudoaneurysm of an SVG is a very rare complication of CABG surgery. In one single case series, the incidence was estimated to be 20 Unknown Graft target vessel LAD LCX RCA Unknown Pseudoaneurysm average size, cm [0,1-2]Resternotomy Total Re-do CABG Re-exploration Post-operative infection [0,1-2]Treatment approach Surgical Percutaneous Covered stent Amplatzer device Coil embolization Thrombin injection Conservative Symptoms Asymptomatic Chest pain Dyspnea Bleeding Hemoptysis Wound infection Weakness Initial diagnostic study CXR Echocardiogram CT chest CAG MRI Complications Death Rupture Bleeding Thrombus Mass effect Fistula
58 (81) 14 (19) 65 13 10 17 32 11 2
(13.8) (23.6) (44.4) (15.2) (2.7)
15 (20.8) 21 (29.1) 34 (47.2) 2 (2.7) 6.7 16 10 6 7
(22.2) (13.9) (8.3) (9.7)
39 19 14 2 2 1 14
(54.2) (26.4) (19.4) (2.8) (2.8) (1.4) (19.4)
22 35 7 3 3 1 1
(30.5) (48.6) (9.7) (4.2) (4.2) (1.4) (1.4)
35 8 11 17 1
(48.6) (11.1) (15.3) (23.6) (1.4)
9 8 9 12 12 3
(12.5) (11.1) (12.5) (16.7) (16.7) (4.2)
LAD, left anterior descending; LCX, left circumflex artery; RCA, right coronary artery; CXR, chest X ray; CT chest, computed tomography of the chest; CAG, coronary angiogram; MRI, magnetic resonance imaging.
However, conservative management may be considered, especially in the asymptomatic patient with multiple comorbidities and limited life expectancy. REFERENCES 1. Memon AQ, Huang RI, Marcus F, et al: Saphenous vein graft aneurysm: Case report and review. Cardiol Rev 2003;11(1):26–34. 2. Keon WJ, Bedard P, Akyurekli Y, et al: Causes of death in aortocoronary bypass surgery: Experience with 1,000 patients. Ann Thorac Surg 1977;23(4):357–360.
J CARD SURG 2015;30:70–73
3. Le Breton H, Pavin D, Langanay T, et al: Aneurysms and pseudoaneurysms of saphenous vein coronary artery bypass grafts. Heart 1998;79(5):505–508. 4. Kallis P, Keogh BE, Davies MJ, et al: Pseudoaneurysm of aortocoronary vein graft secondary to late venous rupture: Case report and literature review. Br Heart J 1993;70(2): 189–192. 5. Karthik S, Grayson AD, McCarron EE, et al: Reexploration for bleeding after coronary artery bypass surgery: Risk factors, outcomes, and the effect of time delay. Ann Thorac Surg 2004;78(2):527–534. 6. Mohara J, Konishi H, Kato M, et al: Saphenous vein graft pseudoaneurysm rupture after coronary artery bypass grafting. Ann Thorac Surg 1998;65(3):831–832. 7. Ramirez FD, Hibbert B, Simard T, et al: Natural history and management of aortocoronary saphenous vein graft aneurysms: A systematic review of published cases. Circulation 2012;126(18):2248–2256. 8. Shreenivas SS, Lilly S, Desai ND, et al: Percutaneous closure of an aortic pseudoaneurysm due to saphenous vein graft dehiscence with an amplatzer vascular plug. JACC Cardiovasc Interv 2013;6(10):1103–1104.
SMER, ET AL. SVG PSEUDOANEURYSM; ONE DISEASE TWO COURSES
73
9. Kubota S, Wakasa S, Ooka T, et al: Successful excision of a saphenous vein graft aneurysm with different methods. Gen Thorac Cardiovasc Surg 2011;59(6):426– 428. 10. Sareyyupoglu B, Schaff HV, Ucar I, et al: Surgical treatment of saphenous vein graft aneurysms after coronary artery revascularization. Ann Thorac Surg 2009;88(6):1801–1805.
SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at the publisher’s website. Video S1. Parasternal long axis view with color flow imaging demonstrating the continuous flow into pseudoaneurysm. Video S2. Parasternal long axis view with definity contrast demonstrating the contrast filling the pseudoaneurysm.
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
70
REVIEW ARTICLE _______________________________________________________________
Saphenous Venous Graft Pseudoaneurysm: A Review of the Literature Aiman Smer, M.D., Venkata Alla, M.D., Satish Chandraprakasam, M.D., Ahmed Abuzaid, M.D., Alok Saurav, M.D., and Jeffery Holmberg, M.D., Ph.D. Cardiology Department, Creighton University Medical Center, Omaha, Nebraska ABSTRACT Saphenous vein graft (SVG) pseudoaneurysm is a rare complication of coronary artery bypass graft (CABG) surgery. A review of literature indicates that almost one third of patients are asymptomatic at detection and a history of operative complications and need for re-exploration after the initial surgery may serve as useful predictors for the development of this rare complication. doi: 10.1111/jocs.12469 (J Card
Surg 2015;30:70–73) Saphenous vein graft (SVG) pseudoaneurysm is a rare and serious complication of coronary artery bypass (CABG) surgery.1 The presentation can vary from an incidental finding on an imaging study to a life-threatening emergency. We report two cases of SVG pseudoaneurysm that reflect the extreme variation in presentation and natural history, and highlight the need for tailored management. In addition, we performed a systematic review of published cases to identify presenting features and predictors of this rare complication. PATIENT PROFILES Both patients have agreed and signed an agreement form to publish their cases Case 1 A 91-year-old female with advanced dementia, hypertension, and three-vessel CABG in 1990 presented for evaluation of an incidental mediastinal mass on chest X-ray (Fig. 1), after a fall. Precordial exam revealed a grade III/VI continuous murmur at the right sternal border. Transthoracic echocardiogram (TTE) showed a large 8 cm 7 cm mass compressing the right ventricular outflow tract (Fig. 2) with evidence of continuous flow into it on color Doppler (Video 1) and contrast administration (Video 2). A chest computed tomography (CT) showed a large pseudoaneurysm
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Aiman Smer, M.D., 3006 Webster St, Omaha, NE 68131. Fax: þ1-402-4494140; e-mail: [email protected]
originating from the diagonal CABG (Fig. 3). Review of the operative records revealed that the surgical course was complicated by hemothorax requiring re-exploration of the chest. Intraoperatively oozing around the proximal anastomosis of the SVG to the diagonal branch was repaired. She remained asymptomatic until this admission. Considering her asymptomatic status, advanced age, dementia, and high risk for operative complications the family elected for a conservative approach without intervention. She remained asymptomatic at three months follow-up visit. Case 2 An 80-year-old male with multiple comorbidities presented with chest pain and dyspnea two weeks after cardiac surgery involving aortic valve replacement, mitral valve repair, and two-vessel CABG. The patient was in acute distress. He was noted to have peripheral edema, jugular venous distension, and bibasilar crackles. TTE showed a large echo dense mass in the anterior pericardial space consistent with a thrombus (Fig. 4). A CT angiogram (CTA) of the chest revealed 4 cm 3 cm pseudoaneurysm of the right CABG and a large pericardial hematoma 11 cm 7 cm with mass effect on the right ventricle and atrium (Fig. 5). Review of operative records indicated that his postoperative course was complicated by bleeding requiring re-exploration. Given his hemodynamic instability, he underwent emergent surgery with hematoma evacuation and repair of the SVG pseudoaneurysm. At the time of surgery, there was a large pseudoaneurysmal cavity communicating with the RCA graft proximal anastomosis to the ascending aorta via a small defect measuring
J CARD SURG 2015;30:70–73
SMER, ET AL. SVG PSEUDOANEURYSM; ONE DISEASE TWO COURSES
71
Figure 1. Chest X-ray antero-posterior supine view demonstrating a large mediastinal mass (arrows).
Figure 3. Computed tomography (CT) of the chest showing the pseudoaneurysm originating from the diagonal coronary artery bypass graft (arrow). AA, ascending aorta; PA, pulmonary artery.
6 to 8 mm at the site of suture dehiscence. The pseudoaneurysm was resected and the defect sutured. The postoperative course was uneventful. A followup visit at 18 months indicates he has been doing well.
surgery and presentation and importantly predictors of this important and potentially fatal complication. A comprehensive search of PubMed and Medline database, using the terms ‘‘pseudoaneurysm, aneurysm, SVG, and CABG,’’ revealed a total of 296 citations. After eliminating duplicate, non-English and true aneurysms articles, we identified 72 reports of SVG pseudoaneurysm. A detailed document of published case reports is available in the supplementary appendix. As illustrated in Table 1, the right CABG is the most commonly affected graft (47%), followed by left circumflex (29%), and left anterior descending arteries (20%). Interestingly, we found that 22% of all patients with this complication had needed surgical re-exploration postoperatively as compared to the Society of Thoracic Surgeons (STS) reported re-exploration rate of 3.1% in all comers undergoing CABG.5 A prior history of operative complications and need for reexploration following the initial surgery may serve as useful clues and a screening imaging study may be warranted in such patients for early diagnosis of SVG pseudoaneurysm.
DISCUSSION A pseudoaneurysm of an SVG is a very rare complication of CABG surgery. In one single case series, the incidence was estimated to be 20 Unknown Graft target vessel LAD LCX RCA Unknown Pseudoaneurysm average size, cm [0,1-2]Resternotomy Total Re-do CABG Re-exploration Post-operative infection [0,1-2]Treatment approach Surgical Percutaneous Covered stent Amplatzer device Coil embolization Thrombin injection Conservative Symptoms Asymptomatic Chest pain Dyspnea Bleeding Hemoptysis Wound infection Weakness Initial diagnostic study CXR Echocardiogram CT chest CAG MRI Complications Death Rupture Bleeding Thrombus Mass effect Fistula
58 (81) 14 (19) 65 13 10 17 32 11 2
(13.8) (23.6) (44.4) (15.2) (2.7)
15 (20.8) 21 (29.1) 34 (47.2) 2 (2.7) 6.7 16 10 6 7
(22.2) (13.9) (8.3) (9.7)
39 19 14 2 2 1 14
(54.2) (26.4) (19.4) (2.8) (2.8) (1.4) (19.4)
22 35 7 3 3 1 1
(30.5) (48.6) (9.7) (4.2) (4.2) (1.4) (1.4)
35 8 11 17 1
(48.6) (11.1) (15.3) (23.6) (1.4)
9 8 9 12 12 3
(12.5) (11.1) (12.5) (16.7) (16.7) (4.2)
LAD, left anterior descending; LCX, left circumflex artery; RCA, right coronary artery; CXR, chest X ray; CT chest, computed tomography of the chest; CAG, coronary angiogram; MRI, magnetic resonance imaging.
However, conservative management may be considered, especially in the asymptomatic patient with multiple comorbidities and limited life expectancy. REFERENCES 1. Memon AQ, Huang RI, Marcus F, et al: Saphenous vein graft aneurysm: Case report and review. Cardiol Rev 2003;11(1):26–34. 2. Keon WJ, Bedard P, Akyurekli Y, et al: Causes of death in aortocoronary bypass surgery: Experience with 1,000 patients. Ann Thorac Surg 1977;23(4):357–360.
J CARD SURG 2015;30:70–73
3. Le Breton H, Pavin D, Langanay T, et al: Aneurysms and pseudoaneurysms of saphenous vein coronary artery bypass grafts. Heart 1998;79(5):505–508. 4. Kallis P, Keogh BE, Davies MJ, et al: Pseudoaneurysm of aortocoronary vein graft secondary to late venous rupture: Case report and literature review. Br Heart J 1993;70(2): 189–192. 5. Karthik S, Grayson AD, McCarron EE, et al: Reexploration for bleeding after coronary artery bypass surgery: Risk factors, outcomes, and the effect of time delay. Ann Thorac Surg 2004;78(2):527–534. 6. Mohara J, Konishi H, Kato M, et al: Saphenous vein graft pseudoaneurysm rupture after coronary artery bypass grafting. Ann Thorac Surg 1998;65(3):831–832. 7. Ramirez FD, Hibbert B, Simard T, et al: Natural history and management of aortocoronary saphenous vein graft aneurysms: A systematic review of published cases. Circulation 2012;126(18):2248–2256. 8. Shreenivas SS, Lilly S, Desai ND, et al: Percutaneous closure of an aortic pseudoaneurysm due to saphenous vein graft dehiscence with an amplatzer vascular plug. JACC Cardiovasc Interv 2013;6(10):1103–1104.
SMER, ET AL. SVG PSEUDOANEURYSM; ONE DISEASE TWO COURSES
73
9. Kubota S, Wakasa S, Ooka T, et al: Successful excision of a saphenous vein graft aneurysm with different methods. Gen Thorac Cardiovasc Surg 2011;59(6):426– 428. 10. Sareyyupoglu B, Schaff HV, Ucar I, et al: Surgical treatment of saphenous vein graft aneurysms after coronary artery revascularization. Ann Thorac Surg 2009;88(6):1801–1805.
SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at the publisher’s website. Video S1. Parasternal long axis view with color flow imaging demonstrating the continuous flow into pseudoaneurysm. Video S2. Parasternal long axis view with definity contrast demonstrating the contrast filling the pseudoaneurysm.
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
