Long-Term Outcome of Percutaneous Exclusion of Huge Saphenous Vein Graft Aneurysms Using Peripheral Covered-Stents as Alternative to Surgical Repair

Abstract: Giant vein graft aneurysms occur infrequently after coronary artery bypass graft surgery and are most often detected incidentally during coronary angiography for suspected angina or as a mediastinal mass on chest radiographs. Hereby, we describe the percutaneous treatment of a huge right coronary artery saphenous vein bypass graft aneurysm by using peripheral stent-graft. Twelve months after the procedure, the aneurysm was completely sealed at computed tomographic angiography with a good distal run-off in the bypass graft. Different strategies adopted and the feasibility as well as the long-term outcomes of this technique are described thoroughly. 

J INVASIVE CARDIOL 2012;24(12):689-691

Key words: coronary artery suregery, complications; SVG aneurysm

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Saphenous vein graft (SVG) aneurysms are a rare complication following coronary artery bypass grafting (CABG) with an estimated rate of <1%. Mild aneurysmal dilation of SVGs are relatively common (14% within 5-7 years of surgery). A literature review from the first reported case in 1975 until now revealed 50 true aneurysms and 26 false aneurysms most of which were detected incidentally during coronary angiography for suspected angina or as a mediastinal mass on chest radiographs.^1-4 In addition, it is important to note that data about graft degeneration are scarce; some case reports are described, but the best modality of treatment is not widely understood.⁵ Herein we report a case of SVG aneurysm where complete closure of the aneurysm was obtained with placement of multiple peripheral covered stents. The technical difficulties encountered during the case and solutions adopted are described in detail, and the importance of mastering coronary and peripheral interventional skills is outlined.

Case Description

An 83-year-old hypertensive female presented in our institution for the acute onset of thoracic chest pain. ECG showed signs of NSTEMI, with 2 mm down-sloping ST-segment depression in the infero-lateral leads. The clinical presentation was complicated by AF with rapid ventricular response, Troponin I was 6.26 ng/ml and no other significant abnormalities were recorded at the routine laboratory examination. The patient had CABG in 1994 with LIMA to LAD, and sequential SVGs to RCA and D1.

A CT scan of the patient’s chest ruled out a mediastinal mass and demonstrated an ostial SVG huge aneurysm (Figure 1) with “whirling flow” aspect suggesting higher risk of sac thrombosis. A decision was made to treat the aneurysm percutaneously.

A long 8 Fr Arrow sheath (Arrow International) was introduced through a right femoral approach, through which an Amplatz left C2 8 Fr catheter (Cordis) was used — after failure of a Multipurpose catheter and Amplatz left C1 (Cordis) — to cannulate the RCA graft (which appeared degenerated, and showed a saccular aneurysm proximally). Then, a 0.014-inch BMW guiding wire (Abbott Vascular) was used to cross the lesion at the site of anastomosis with the graft. Due to poor catheter back up, this wire was then exchanged with an Ironman 300 cm super stiff wire (Abbott) inside an over-the-wire Maverick 2 x 20 mm balloon (Boston Scientific) followed by direct deployment of a 3 x 20 mm Skylor stent (Invatec) inflated at 16 atm for 15 seconds followed by another Skylor stent (2.75 x 16 mm) distally to treat the stenosis at the level of the anastomosis and native RCA, respectively (Figure 2). Then, a balloon expandable 6 x 22 mm Advanta covered stent (Atrium Medical) was deployed at the distal half of the aneurysm with generous coverage of the native graft in order to improve distal sealing. Another 6 x 22 mm Advanta stent was deployed at the proximal half, but, despite extreme care in placement to overlap the stents, the proximal one dislodged from the distal one during maximal inflation in attempts to oversize it (22 atm for 10 sec). This resulted in a small area of leakage into the aneurysm in between (Figures 3A, 3B, and 3C). We decided to put in a third covered stent, however, the size of the third available in our stockroom was too big to be advanced inside the guiding catheter. Therefore, the latter was withdrawn and an attempt to deploy the stent from the Arrow sheath failed due to the lack of support of the Ironman wire at the ostium. A Glidecath (Terumo Corporation) was then introduced to the distal RCA, and the 0.014-inch Ironman wire exchanged with a 0.035-inch Storque guide wire (Cordis), which again did not provide enough ostial support for stent advancement. Thus, the wire was exchanged for an Amplatz 0.35-inch super stiff (Boston Scientific) which was extremely carefully placed into the distal native RCA and finally the third Advanta 5 x 38 mm stent deployed, covering both previous stents and closing the site of leakage (Figures 4A, 4B, and 4C). The patient remained asymptomatic and was discharged 2 days after the procedure with instruction to continue aspirin 100 mg and clopidogrel 75 mg prescription for 12months. Clinical follow-up was performed at 1, 6, and 12 months and the patient remained free of cardiac symptoms. CT angiography performed 12 months later to ensure the patency of the deployed stents revealed a complete sealing of the aneurysm with patency of the deployed covered stents as well as the other two stents deployed in the native right coronary and left circumflex arteries (Figures 5A, 5B, and 5C).

Conclusion

Giant vein graft aneurysms may present interventional management challenge, and this case highlights the feasibility of a complex percutaneous coronary endovascular approach as an alternative to surgery with satisfactory long-term outcomes.

References

1. Williams ML, Rampersaud E, Wolfe WG. A man with saphenous vein graft aneurysms after bypass surgery. Ann Thorac Surg. 2004;77(6):1815-1817.
2. Roth M, Sprengel U, Kraus B, Klovekorn WP, Bauer EP. Symptomatic aneurysm of a saphenous vein graft with compression of the right atrium. Heart Surg Forum. 1999;2(4):338-340.
3. Kalimi R, Palazzo RS, Graver LM. Giant aneurysm of saphenous vein graft to coronary artery compressing the right atrium. Ann Thorac Surg. 1999;68(4):1433-1437.
4. Gruberg L, Satler LF, Pfister AJ, Monsein LH, Leon MB. A large coronary artery saphenous vein bypass graft aneurysm with a fistula: case report and review of the literature. Catheter cardiovasc Interv. 1999;48(2):214-216.
5. Dimopoulos AK, Manginas A, Pavlides G, Cokkino DV. PCI in severely degenerated saphenous vein graft using a novel mesh-covered stent together with a conventional embolic protection system. Hellenic J Cardiol. 2009;50(5):429-435.

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From the ¹Division of Cardiology, University of Modena and Reggio Emilia, Modena, Italy; ²Department of Cardiology, Ain Shams University, Cairo, Egypt; and ³Department of Cardiology, Cardiac Cath Lab, University of Tor Vergata, Rome, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted April 24, 2012, provisional acceptance given May 4, 2012, final version accepted May 14, 2012.

Address for correspondence: Giuseppe Massimo Sangiorgi, FESC, FSCAI, FSICI-GISE, Department of Cardiology, Cardiac Cath Lab, University of Tor Vergata, Rome, Italy. Email: gsangiorgi@gmail.com