70-year-old male with a remote history of CABG and a new mediastinal mass.
Patient presented to our institution for a coronary angiogram. He had a past history of coronary atherosclerosis and a four-vessel CABG thirteen years ago. A recent chest x-ray showed a new mass measuring about 4 cm located at the right heart border, which was not present from a film three months prior. Subsequent CT scan of the chest confirmed the presence of a large vascular structure.A cardiac catheterization was done three months ago due to unstable angina. It showed a patent SVG to the distal RCA, which was dilated and ectatic. The mid- portion of the graft had a 1.5 cm ulcerated pocket with thrombus. The SVG to D1 & D2 were occluded and the OM1 graft & LIMA to LAD were patent. Subsequent to the injection of the LIMA the patient developed anterior ST elevations. An intraaortic balloon pump was placed, and balloon angioplasty was done to the distal LAD. He also experienced an embolic event to his right lower extremity, which necessitated an embolectomy to his right femoral artery.He was placed on coumadin prior to discharge.Patient also had a history multiple vascular aneurysms with a history of AAA repair twice and left iliac artery aneurysm coil embolization. A transthoracic echocardiogram showed an ejection fraction of 30% with moderate aortic and mitral valve insufficiency. He also has hypercholesterolemia and COPD with a 50 pack-year history of smoking.Examination showed a BP of 101/56, a pulse of 82. He had a normal JVP, clear lungs, a laterally displaced impulse with a 2/6 diastolic murmur, and palpable peripheral pulses. ECG showed sinus rhythm and LVH. Cardiac catheterization showed an aneurysm in the RCA vein graft, measuring about 4X6 cm in the vicinity of the ulcer seen in the coronary angiogram from five months ago. The LIMA and distal LAD were patent, and he had moderate to severe aortic insufficiency on aortography.
The coumadin was halted and he was referred for combined aortic valve replacement and aneurysmectomy. He also had a new vein graft to the RCA and a marginal artery. Upon visual inspection, the vascular mass appeared to be a thin-walled structure consistent with a pseudoaneurysm. Five months later, the patient is doing fine.
This case illustrates the development of a pseudoaneurysm in a heavily atherosclerotic and degenerated coronary vein graft thirteen years post-CABG. It is reported in the literature that atherosclerosis is the etiology of the late vein graft aneurysms.1 Possible treatment options include surgery, percutaneous coil embolization, or covered stenting.2 The recent initiation of coumadin may have caused expansion through dissolution of endovascular thrombus and increased Laplacian forces on the vein graft wall. This case also underscores the importance of ruling out vascular aneurysms in patients with prior coronary bypass grafting when new mediastinal masses are seen on noninvasive imaging.
S.C. Kessel, None.