Page 19 - Delaware Medical Journal - December 2015
P. 19
CASE REVIEW
CASE REPORT
A 66-year old woman was admitted to the hospital with chest pain. She had
a history of end-stage renal disease
and CABG in 1996 with a left internal mammary artery (LIMA) graft to the
left anterior descending (LAD) artery and a SVG to distal RCA. Four months prior to this admission, a left heart catheterization performed for unstable angina demonstrated a subtotal occlusion of the SVG to RCA ostium that was successfully intervened upon with a bare mental stent. This vein graft was also found to have an aneurysmal dilatation in the mid portion that was medically managed. During this admission she presented with accelerating angina over the preceding 24 hours, complicated
by congestive heart failure. Physical exam reveals a new to-and-fro murmur. Hospital work-up showed elevated cardiac enzymes consistent with a non-ST elevation myocardial infarction. The chest pain did not respond to medical therapy so she was transferred emergently to the cardiac catheterization laboratory for further evaluation.
Selective coronary angiography revealed
of the SVG to RCA ostium. Further, the previously noted aneurysm in the mid end of the graft on angiography explaining (Figure 1). A right heart catheterization was performed and oximetry studies obtained, demonstrating an RA saturation of 85 percent signifying
FIGURE 1
Selective graft angiography showing SVG Aneurysm connected to RA.
atrium resulted in an overwhelming volume overload on the right ventricle and explained the overt heart failure exacerbation on presentation. The ischemia caused by shunting the blood away from the right coronary graft territory and the volume overload of the right ventricle made closure of Although these cases are usually
managed surgically, surgery was not an
territory coursed along the sternum with risk of severing the artery with repeat sternotomy. Cardiac Computed Tomography Angiography (CCTA) revealed that SVG aneurysm was large measuring 2.6 x 3.1 cm and it was partly thrombosed peripherally (Figure 2A).
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