Aneurysms of coronary artery grafts though rare have been well reported in literature. Most of these reports however describe patients with single aneurysms. We would like to describe a patient presenting with three simultaneous Saphenous Vein Graft (SVG) aneurysms and an aortic pseudoaneurysm.
A 71 year old female presented with shortness of breath, orthopnea, pedal edema and retrosternal chest pain. Past medical history was significant for hypertension and coronary artery disease for which she underwent saphenous vein bypass graft to the Right Coronary Artery (RCA), Left Anterior Descending Artery (LAD) and Left Circumflex Artery (LCX). Physical examination revealed an elderly woman with a respiratory rate of 24, pulse rate of 130 and a blood pressure of 117/78. She had jugular venous distension 3 cm above the sternal angle, bilateral basal rales on chest examination and pitting edema in both lower extremities. Laboratory revealed anemia with hemoglobin of 8.8, normal white cell count and electrolytes. Serial cardiac enzymes were normal and electrocardiograms showed no evidence of acute ischemia. Chest x-ray (CXR) revealed some vascular prominence and mediastinal widening compared to her prior CXR done 15 months before. A CT scan of her chest ordered to rule out aortic dissection showed pseudoaneurysms of the SVG to the RCA (3.4 cm), true aneurysms of LAD (2 cm) and LCX (1.6.cm) and also a large pseudoaneurysm of the Aorta (7.7cm). A cardiac catheterization confirmed the findings. Options of surgical and percutaneous procedures were discussed but the patient opted for conservative management. The patient was treated for congestive heart failure, discharged home, is currently asymptomatic and doing well at one year follow up.
Aneurysms of the saphenous vein grafts, though rare must be considered in the differential diagnosis of mediastinal masses in patients who have undergone coronary artery bypass surgery. Aneurysm of saphenous vein grafts (SVG) is a rare late complication of coronary bypass surgery with reported incidence of about 0.07 %. Pseudoaneurysm formation of saphenous vein grafts have been attributed to technical factors such as disruption of suture lines or infection while true aneurysms are related to the progression of degenerative atherosclerotic disease. Hyperlipidemia and hypertension remains a significant contributor to the pathogenesis. Clinical presentation is usually secondary to incidental mediastinal mass, angina or myocardial infarction due to progressive lumen occlusion, distal embolization and compression of surrounding structures, including grafts and coronary arteries. Rarer presentations include fistula formation between aneurysm and right atrium or ventricle, and hemoptysis secondary to rupture into right middle bronchus. Though chest x-ray is usually abnormal, CT remains the mainstay of diagnosis. It differentiates between true and pseudoaneurysms, estimates size and can describe the presence of intraluminal thrombus. Other imaging modalities include echocardiography, magnetic resonance imaging and angiography. Therapeutic options include surgical exclusion or resection of the aneurysm with or without revascularization. Percutaneous coil embolization and covered stent placement has been well described. Conservative management may also have a role. Almost all prior case reports have described single graft aneurysms and multiple SVG aneurysms are extremely rare. Our patient had three concomitant saphenous vein graft aneurysms,a large aortic pseudoaneurym and is doing well with conservative management. A similar presentation has not been described before to the best of our knowledge.
Aneurysms of the saphenous vein grafts, though rare must be considered in the differential diagnosis of mediastinal masses in patients who have undergone prior coronary artery bypass surgery.The role for conservative management in these patients need to be explored further.
T. Majumdar, None.