JAOA • Vol 106 • No 11 • November 2006 • 663-666
Multiple Aortocoronary Bypass Saphenous Vein Graft Aneurysms in a 77-Year-Old Man
Anne-Marie Moukala-Cadet, DO;
Stephen J. Mitrosky, DO;
Glenn D. Miller, MD;
Donald A. Swayze, DO;
Eric J. Fielding, MD;
Michael J. Hoh, DO;
Arthur J. Dortort, DO;
Melissa A. Nebzydoski, DO;
Karla Cyphert, RT
From Chenango Memorial Hospital (Dr Moukala-Cadet), the Departments of
Internal Medicine (Dr Mitrosky), Cardiology (Dr Miller), Radiology (Drs Swayze
and Fielding and Ms Cyphert), and Emergency Medicine (Drs Hoh and Dortort) at
Clarion Hospital in Clarion, Pa, and the Dewitt Army Family Medicine Residency
Program at Dewitt Army Community Hospital in Fort Belvoir, Va (Dr Nebzydoski).
The study was completed at Clarion Hospital.
Address correspondence to Anne-Marie Moukala-Cadet, DO, Chenango Memorial
Hospital, 179 N Broad St, Norwich, NY 13815–1097. E-mail:
amoukala{at}juno.com
Aneurysms of aortocoronary saphenous vein bypass grafts are a rare
complication of coronary artery bypass grafts. The authors report the
incidental finding of four aneurysms in two aortocoronary saphenous vein
bypass grafts in a 77-year-old man with progressive generalized weakness, left
facial drooping, and digitalis toxicity. A brief review of the literature on
this rare condition is also provided.
The most common symptoms of aortocoronary saphenous vein bypass graft
(SVBG) aneurysms are retrosternal chest pain or discomfort associated with
hemoptysis, hypotension, nausea and vomiting, and shortness of breath. Such
aneurysms may occur in coronary artery bypass grafts (CABGs). We observed this
rare occurrence in a 77-year-old white man with digitalis toxicity and
possible transient ischemic attack on initial examination. The patient was
brought to the emergency department because of generalized weakness and
difficulty walking. He had not been able to stand and walk for 3 days.
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Medical History
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The patient had undergone two CABGs for severe multivessel coronary artery
disease, 17 and 21 years previously. The medical record for his 1984 CABG was
unavailable. The record of his 1988 procedure described a reverse saphenous
vein graft that was anastomosed to the right coronary artery; another segment
of the saphenous vein graft was anastomosed to the obtuse marginal artery; the
same vein graft was anastomosed to the diagonal artery sequentially; and the
left internal mammary artery was anastomosed to the left anterior descending
coronary artery (LADCA).
One year prior to the current hospitalization, the patient underwent
placement of a single-chamber implantable ventricular defibrillator and a
single-chamber pacemaker with the minimum rate set at 40 beats/min. Cardiac
catheterization at that time revealed severe disease in three native coronary
arteries with a 70% or worse left main lesion and total occlusion of the
LADCA, the circumflex artery, and the right coronary artery. The following
grafts were identified: left internal mammary graft to the mid-LADCA, widely
patent; LADCA collateralized to the distal right coronary artery; saphenous
vein grafted to the circumflex marginal branch with extreme ectasia and
multiple aneurysmal segments but surprisingly good flow into a large marginal
branch; and saphenous vein graft to the right coronary artery occluded at its
origin. Severe left ventricular dysfunction with ejection fraction about 15%
to 20% and moderately severe mitral valve regurgitation were also noted.
The patient's history also included atrial fibrillation, benign prostatic
hypertrophy, chronic obstructive pulmonary disease, hypertension, myocardial
infarction, type 2 diabetes mellitus, and urinary retention. In addition, he
had abused alcohol for more than 30 years and smoked cigarettes for more than
60 years.
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Clinical Evaluation
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On initial examination, the patient reported that he had fallen and could
not get up. He also reported symptoms of fatigue with generalized weakness
that started 4 months previously and had progressively worsened until
admission. He denied having chest pain and worsening of shortness of breath.
He appeared awake and alert and had a mild left facial droop. He was afebrile,
his blood pressure was 102 mm Hg systolic and 60 mm Hg diastolic; pulse rate,
44 beats/min; respiratory rate, 24/min; and oxygen saturation, 91% in room
air. There was no jugular venous distention or bruit on neck examination.
Decreased air entry at the right lung base was found, with no wheeze, rales,
or rhonchi. Results of abdominal examination were unremarkable. A neurologic
examination revealed normal muscle strength and tone. An osteopathic
structural examination revealed a normal spinal curve for the patient's age.
Examination of the lower extremity showed venous stripping. No edema was
present, and pulses were palpable bilaterally. The patient's skin appeared
dry.
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Figure 1. Chest radiograph, anteroposterior view, depicting a contour change of
the heart on the right side (arrow).
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Figure 3. Contrast-enhanced multidetector computed tomographic scan showing
coronary artery bypass grafts. The arrow points to an aneurysm corresponding
to the contour change seen on the chest radiograph film in
Figure 1.
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A complete blood cell count showed a white blood cell count of 8.32
(reference range, 4.6–10.2). Hematocrit was 42% (reference range,
43.5%–53.7%); hemoglobin, 13 g/dL (reference range, 14.1–18.1
g/dL); and platelet count, 248 x103/µL (reference range,
142–424 x103/µL). Chemical analysis revealed the
following: sodium, 140 mEq/L (reference range, 136–146 mEq/L);
potassium, 3.9 mEq/L (reference range, 3.5–5.1 mEq/L); chloride, 101
mEq/L (reference range, 98–106 mEq/L); CO2, 32.2 mEq/L
(reference range, 23–29 mEq/L); glucose, 143 mg/dL (reference range,
83–100 mg/dL); blood urea nitrogen, 36 mg/dL (reference range,
8.0–25.0 mg/dL); and creatinine, 1.2 mg/dL (reference range,
0.7–1.3 mg/dL). Cardiac studies found B-type natriuretic peptide, 757
pg/mL (reference range, 0–100 pg/mL); first creatine kinase, 1444 U/L
(reference range, 32–250 U/L); second creatine kinase, 713 U/L; first
creatine kinase-MB fraction, 21.6 ng/mL (reference range, 0–10.4 ng/mL);
second creatine kinase-MB fraction, 5.2 ng/mL; first troponin I, 0.33 mg/mL
(reference range, 0–0.4 mg/mL); second troponin I, 0.16 mg/mL; and
digoxin, 3.2 ng/mL (reference range, 0.8–2.1 ng/mL).
Results of a 12-lead resting electrocardiogram done prior to examination
showed atrial fibrillation with a ventricular response rate of 63 beats/min
and diffuse ST-T abnormalities.
An enhanced multidetector CT scan of the brain revealed an old left
temporal occipital infarct. No abnormal enhancement was seen. A chest
radiograph revealed changes consistent with cardiomegaly and an intact
pacemaker defibrillator system (Figure
1) and showed a retrocardiac nodular density in the lateral
view (Figure 2). This
was a new finding compared with that obtained by chest radiographic
examination done 4 months earlier and 1 year earlier.
Multidetector CT scan of the chest was done before and after intravenous
contrast was injected. Findings were consistent with those seen on the chest
radiograph in the anteroposterior
(Figure 3) and lateral
(Figure 4) views. The
aorta showed some atheromatous change, and the aortic root measured 4 cm. No
hilar or mediastinal lymphadenopathy was seen. There were what appeared to be
aneurysms of the CABGs on the right and left sides. The right-sided graft
revealed a proximal aneurysm with maximum dimension of 4 cm, with an
intraluminal clot and a true lumen of 16 mm
(Figure 5). Distally,
there was a second aneurysm measuring almost 4.4 cm, with a clot and a true
lumen of about 9 mm (Figure
6). The left CABG revealed a proximal aneurysm measuring 2.6
cm, with a true lumen of about 2 cm
(Figure 7). A second
aneurysm was found distal to the first, measuring 2.4 cm, with a small true
lumen (Figure 8).
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Figure 4. Multidetector computed tomographic scan, sagittal view, showing
reconstruction of the chest. The arrow points to dilated pulmonary vessels
that coincide with the density seen on the chest radiograph film in
Figure 3.
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Figure 5. Multidetector computed tomographic scan of the chest, axial plane. The
arrow points to the proximal aneurysm of the right-sided aortocoronary
saphenous vein bypass graft.
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Figure 6. Multidetector computed tomographic scan of chest, axial plane. The
arrow points to the distal aneurysm of the right-sided aortocoronary saphenous
vein bypass graft.
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Figure 7. Multidetector computed tomographic scan of the chest, axial plane. The
arrow points to the proximal aneurysm of the left-sided aortocoronary
saphenous vein bypass graft (retrosternal view).
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Figure 8. Multidetector computed tomographic scan of the chest, axial plane. The
arrow points to the distal aneurysm of the left-sided aortocoronary saphenous
vein bypass graft (retrosternal view).
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It was determined that the patient had a transient ischemic attack. Blood
clots found in the patient's bladder, most likely caused by long-term use of
indwelling urinary catheters for chronic urinary retention and benign
prostatic hypertrophy, were flushed out by a large catheter. His insulin
therapy was reduced, owing to the controlled hospital diet, and he was also
converted to oral furosemide from intravenous administration. The patient did
very well after diuresis. His digoxin level decreased to within the
therapeutic range. His strength improved with minimal intervention. His facial
droop resolved. Serial cardiac markers and an electrocardiogram ruled out
acute myocardial injury.
The patient and his family refused any evaluation for repair of the four
aneurysms, and the patient obtained a do-not-resuscitate order. With stable
cardiopulmonary status, the patient was discharged to an extended care
facility for rehabilitation.
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Comment
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After CABG, aneurysms of aortocoronary SVBGs are reported from a few days
to 21 years after surgical
intervention.4 To
our knowledge, the literature has not reported four aneurysms occurring
simultaneously. These aneurysms are usually discovered incidentally as a
mediastinal or cardiac mass on chest
radiograph1,5,7
in patients who have had CABG. Diagnosis is confirmed by CT
scan,5
echocardiography,3
and magnetic resonance
imaging.1,4
The diagnostic gold standard is coronary
angiography.4,7
Two types of CABG aneurysms have been reported: true aneurysms and
pseudoaneurysms. True aneurysms occur at the body of the
graft4 and involve
the entire vessel
wall.5 The origin of
true aneurysms is unknown, though risk factors may include
atherosclerosis4 and
vessel trauma during
harvest.5
Pseudoaneurysms have been reported at the site of anastomosis, either
proximally or distally. The etiologic process of pseudoaneurysms is similarly
unknown.1,4,5
Iatrogenic causes such as suture defects and deficiency in the preparation of
the saphenous vein have been
implicated.4
There is no consensus on clinical management of SVBG
aneurysms.8
Intervention may be considered elective, urgent, or emergent depending on
patient presentation. The treatment plan recommended by some experts is
immediate surgical intervention regardless of aneurysm
size4 to avoid
potential complications of coronary embolization, fistula formation, or
rupture.5 Other
experts recommend treatment based on the size and growth rate of the aneurysm,
comorbid conditions, and overall life
expectancy.8 In this
model, surgical intervention is offered to patients with low operative risk
only.8 Medical
management has not been predictive of positive
outcomes,4 and an
early aggressive surgical approach has also failed to demonstrate increased
rates of
survival.8
In conclusion, aortocoronary SVBG aneurysms should be a part of the
differential diagnosis for patients whose medical history includes CABG
regardless of the time interval between surgical intervention and onset of the
following symptoms: retrosternal chest pain, shortness of breath, nausea,
vomiting, hemoptysis, and hypotension.
Submitted October 5, 2005;
revision received March 10, 2006;
accepted March 21, 2006.
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References
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1. Le Breton H, Pavin D, Langanay T, Roland Y, Leclercq C, Beliard JM,
et al. Aneurysm and pseudoaneurysms of saphenous vein coronary artery bypass
grafts. Heart. 1998;79:505–508. Available at:
http://heart.bmjjournals.com/cgi/content/full/79/5/505.
Accessed October 10, 2006.2. Cadaret L, William Cotts W, Richenbacher W. Images in
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2000;101:1075–1077. Available at:
http://circ.ahajournals.org/cgi/content/full/101/9/1075.
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3. Dzavik V, Lemay M, Chan KL. Echocardiographic diagnosis of an
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SR. Giant saphenous vein graft aneurysm. Angiology.2004; 55:587
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6. Nishimura Y, Okamura Y, Hiramatsu T, Mori H, Hayashi H, Komori S.
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7. Gupta S, Khan T, Stephenson LW, Cooley D, Schnader J. Clinical
conference on management dilemmas: a growing vascular mass in the chest.
Chest. 2000;118:1769–1775. Available at:
http://www.chestjournal.org/cgi/content/full/118/6/1769.
Accessed October 10, 2006.
8. Dieter RS, Patel AK, Yandow D, Pacanowski JP Jr, Bhattacharya A,
Gimelli G, et al. Conservative vs invasive treatment of aortocoronary
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Medical History
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