Page 22 - Delaware Medical Journal - December 2015
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CASE REVIEW
Symptoms usually present when the aneurysm grows in size and causes compression on surrounding structure aneurysm and surrounding structure.5 Fistulae to the adjacent cardiac chambers is a rare complication and was only reported in a handful of cases in the literature.4 Symptoms resulting from the chest pain, angina and/or shortness
of breath, and in extreme cases, overt heart failure. Development of abrupt chest pain seems to occur with acute
recurrent angina and impending heart
the aneurysm and the tight atrium made
managing this patient.
Treatment options for SVG aneurysms include surgical, percutaneous, and conservative interventions. The most commonly utilized approach is surgical, comprising 58 percent of all cases reported in the literature.5 This entails aneurysmal resection or ligation, followed by bypass grafting in cases with
also not a candidate for medical therapy secondary to the recurrent ischemia
and impending heart failure. Therefore percutaneous intervention was the only feasible option. The most commonly
used percutaneous approach in the literature has been coil embolization of the aneurysm.8 Amplatzer vascular plug (AGA Medical, Golden Valley, MN) is a newer approach.9 However, in this case coiling the aneurysm or using the vascular plug were not considered optimal given the right atrium, increasing the risk of embolization to the pulmonary system. Also, both techniques may carry the risk arterial system. Recently, covered stents have been used with success to isolate
the aneurysm from the graft lumen.10
To the best of our knowledge, this is communication of a SVG aneurysm to
the RA that was successfully treated utilizing multiple peripheral covered stents, and should remain the treatment of choice in patients in whom repeat surgical intervention is not an option where a large area of the myocardium is supplied by the affected graft. Covered stents are effective in excluding the aneurysm while maintaining myocardial perfusion.
CONCLUSION
Although until recently surgery was the standard of care in managing complicated an attractive alternative option and is associated with better outcomes than surgical and conservative options. To the reported case of a successful closure aneurysm to the RA utilizin g multiple peripheral covered stents.
Percutaneous interventions, although historically reserved for patients who are poor surgical candidates, have been utilized more frequently in the past 10 years concurrent with advances in percutaneous techniques.7
away from the territory bypassed by
the graft constituting a coronary steal the aneurysm and right atrium or ventricle enormous, this may result in high output heart failure.3,5 6 In our patient, acute onset of accelerating angina developed most likely as a result of a steal phenomenon as well as the ostial stenosis. A continuous secondary to ostial restenosis might have resulted in myocardial ischemia in the territory of the heart supplied by the distal with an added burden of volume overload on the right ventricle resulting in a
high output heart failure. Therefore the
6 Percutaneous interventions were reported in 16 percent of reported cases, including coil embolization, Amplatzer vascular occlusion, or covered stent placement. Conservative management was used in 20 percent of cases. Mortality rates for reported cases of surgical, percutaneous, and conservative management were 13.9 percent, 6.1 percent, and 23.8 percent, respectively.5
Percutaneous interventions, although historically reserved for patients who are poor surgical candidates, have been utilized more frequently in the past
10 years concurrent with advances in percutaneous techniques.7 Our patient was at very high risk for a surgical approach secondary to previous thoracotomy and the course of the LIMA behind the sternum. She was
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Del Med J | December 2015 | Vol. 87 | No. 12
