Management of Saphenous Vein Graft Aneurysm
Presenter
Lauren Balkan, MD, Beth Israel Deaconess Medical Center, Boston, MA
Lauren Balkan, MD, Beth Israel Deaconess Medical Center, Boston, MA
Keywords: Complications, Coronary and Stable Ischemic Heart Disease (SIHD)
Title: Management of a Saphenous Vein Graft Aneurysm Introduction: Saphenous vein graft (SVG) aneurysms are a recognized complication of coronary artery bypass graft (CABG) surgery and can result in adverse events such as graft thrombosis due to turbulent flow within the aneurysmal segment, rupture, or local compression related to aneurysm size. SVG aneurysms may be symptomatic and detected by angiography or incidentally identified on cross-sectional imaging. Treatment options include redo surgery or percutaneous intervention, such as exclusion of the aneurysm with a covered stent or coil embolization. We present a case of a large, incidentally discovered SVG aneurysm successfully treated with a covered stent. Clinical Case: The patient is a 69-year-old man with coronary artery disease status post CABG in 1999, including a left internal mammary artery graft to the left anterior descending artery and SVGs to the right posterior descending (PDA), first diagonal, and first obtuse marginal arteries. He presented with abdominal pain and was incidentally noted to have a large (~4 cm × 5 cm) aneurysm associated with the right coronary artery on an abdominal CT scan. This was subsequently confirmed on invasive coronary angiography, and he was referred for percutaneous intervention. The diagnostic angiogram confirmed a large aneurysm of the distal SVG to the PDA. The size of the aneurysmal neck was unclear on angiography; however, correlation with the previously obtained CT scan demonstrated a narrow aneurysmal neck, making antegrade wiring favorable. We therefore proceeded with a plan to exclude the aneurysm with a covered stent. An alternative approach, if wiring of the vein graft proved difficult, would have been intervention on the native right coronary artery followed by coiling of the graft. After wiring the vessel through an 8-French guide catheter, we performed intravascular ultrasound imaging. This confirmed that the non-aneurysmal segment measured over 6 mm in diameter, which was too large for a coronary covered stent. At that point, we transitioned from a 0.014 system to a 0.018 system and planned treatment with a 7.0 mm × 50 mm covered stent. During the system exchange, the distal wire position of the Glide Advantage wire was lost and subsequently re-advanced. After predilation with 4.0 and 5.0 mm balloons, the stent was successfully delivered and deployed. On subsequent angiography, a small distal wire perforation was identified. Because wire position had been lost during the case, it was unclear which branch vessel contained the perforation. A microcatheter was sequentially advanced into each branch vessel, and the branch with the perforation was identified on selective angiography through the microcatheter. The perforation was treated with coil embolization. Discussion: SVG aneurysms are an uncommon but important late complication of CABG and can be successfully treated percutaneously. This case highlights the value of multimodality imaging in defining aneurysm anatomy and guiding intervention. Successful exclusion with a covered stent required the use of a 0.018 system and a peripheral covered stent for appropriate sizing. Prompt recognition and careful intraprocedural management of complications, such as wire perforation, are essential for optimal outcomes.