Page 18 - Delaware Medical Journal - December 2015

Aortocoronary Saphenous Vein Graft Aneurysm with Fistula to the
Right Atrium: Percutaneous Management of Surgical Complication
Armin Barekatain, MD, MSc.; Zaher Fanari, MD; Sandra A. Weiss, MD
Abstract: Aneurysmal dilatation of aortocoronary saphenous vein grafts (SVG) is a rare but known complication after coronary artery bypass grafting (CABG). They are most commonly found incidentally, although some may present with unstable angina or myocardial infarction (MI). Rarely, these aneurysms can develop into fistulas to the neighboring cardiac chambers. We report the case of a 66-year old woman with a history of CABG in 1996 with a left internal mammary artery (LIMA) graft to the left anterior descending and a SVG to distal right coronary artery presenting with non-ST segment elevation myocardial infarction (NSTEMI) complicated with congestive heart failure. Selective Coronary and Graft angiography showed an aneurysm in the mid SVG with a fistula into the right atrium (RA) resulting in a significant left to right shunt. The significant left to right shunt diverted blood flow from right coronary artery territory resulting in recurrent ischemia and angina and introduced a significant volume overload on the right ventricle resulting in over heart failure. Secondary to the course of LIMA graft along the sternum, surgery was not an option. Secondary
to continued symptoms percutaneous intervention was performed with placement of two 6.0 x 50 mm Viabahn self- expanding covered stent with aggressive post-dilation resulting in successful closure with no residual flow. Percutaneous intervention is shown to be an effective approach to manage both aortocoronary fistula and grafts ruptures and is associated with better outcomes than surgical and conservative options. To the best of our knowledge, this is the
first reported case of a successful closure of fistulous communication of a SVG aneurysm to the RA utilizing multiple peripheral covered stents.
Key Words: Percutaneous closure, graft, aneurysm, fistula, complication.
IntroductionFirst described by Riahi and colleagues in 1975, aneurysmal dilatation of aortocoronary
saphenous vein grafts (SVG) is a rare but known complication after coronary artery bypass grafting (CABG).1 They are most commonly found incidentally, although some may present with unstable angina or myocardial infarction. Rarely, that is usually associated with myocardial ischemia or heart failure.2 Although medical and surgical options were once the mainstay of management of these solution. We report a rare case of an aneurysm of the SVG to right coronary percutaneous intervention.
370 Del Med J | December 2015 | Vol. 87 | No. 12
Abstract