Page 20 - Delaware Medical Journal - December 2015
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CASE REVIEW
FIGURE 2
Figure 2A: Cardiac CT showing the partially thrombosed SVG aneurysm measuring 2.6 x 3.1. Figure 2B: Cardiac CT showing the inferior fistula to RA.
CABG. Aneurysms of aortocoronary SVGs are late but infrequent complications of CABG, usually manifesting 10 to 20 years after surgery.2 In one case series, an incidence of 0.07 percent was estimated from a review
of more than 5,500 grafts at a single institution.3 SVG aneurysms are often
A distinction should be made between a true aneurysm, usually a late complication of bypass surgery, and a pseudoaneurysm. localized or diffuse dilation of an artery with a diameter at least 50 percent greater than the normal size of the artery. If
the wall of the aneurysm contains all three usual layers of blood vessel — the intima (inner layer made of endothelial cells), media (contains muscular elastic as true aneurysm. If the aneurysm does not involve all of the vessel wall layers then it is labeled as pseudoaneurysm. The mechanism and timing behind each type of aneurysm is different. True aneurysms are atherosclerotic in nature and appear
as a late postoperative complication
located along the inferior aspect of the aneurysm. (Figure 2B).
PROCEDURE DETAILS
Given the lack of surgical options and
the presence of continued symptoms,
a decision for a percutaneous intervention was made. After therapeutic anticoagulation was achieved, an 8 French MPA1 guiding catheter was used to engage the ostium of the SVG to RCA. Balloon angioplasty of the ostial in-stent restenosis was performed using a 3.5 x 12 mm balloon. A Volcano Eagle Eye IVUS catheter was then advanced over a 0.014- in ProWater wire to obtain measurements of the SVG for the purpose of the stent sizing. The wire was then exchanged
for a 0.018-in Platinum Plus wire via a QuickCross catheter. The use of a distal protection device was considered, but was not feasible because the intervention was performed over a 0.018-in system and the distal protection devices available
in our lab were 0.014-in compatible systems only. Over the 0.018-in Platinum Plus wire a 6.0 x 50 mm Viabahn self- expanding covered stent was implanted. Despite post dilatation, there remained (Figure 3A), prompting the placement of a second 6.0 x 50 mm Viabahn stent. This was then post-dilated angiography showed complete sealing
of the aneurysm with no evidence of communication with the RA (Figure 3B). Finally, the ostium of the SVG to RCA was stented using a Promus Premier 4 X 12 mm DES. The patient was placed on dual antiplatelet therapy and experienced complete and durable resolution of angina symptoms. Repeated CCTA showed thrombosis of the aneurysm with no (Figure 4).
DISCUSSION
This case demonstrates a large SVG aneurysm that developed 18 years after
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Del Med J | December 2015 | Vol. 87 | No. 12
