Case Report
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Jun 26, 2015; 7(6): 351-356
Published online Jun 26, 2015. doi: 10.4330/wjc.v7.i6.351
Giant saphenous vein graft pseudoaneurysm to right posterior descending artery presenting with superior vena cava syndrome
Andres Vargas-Estrada, Dianna Edwards, Mohammad Bashir, James Rossen, Firas Zahr
Andres Vargas-Estrada, James Rossen, Firas Zahr, Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, United States
Dianna Edwards, Department of Internal Medicine, University of Iowa hospitals and Clinics, Iowa City, IA 52242, United States
Mohammad Bashir, Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, United States
Author contributions: Vargas-Estrada A and Edwards D conceived, designed and wrote the report; Rossen J and Zahr F performed the diagnostic coronary angiogram and made critical revisions to the discussion content; Bashir M provided the intraoperative echocardiographic images, performed the surgical procedure and guided the discussion regarding treatment options; the manuscript has been read and approved by all the authors.
Ethics approval: This is a clinical case report. All patients related identification information has been avoided according to the policy of University of Iowa Hospitals and Clinics and the Health Insurance Portability and Accountability Act (HIPPA) by the United States.
Informed consent: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest: All authors have no conflict-of interest to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Firas Zahr, MD, Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52242, United States. andres-vargasestrada@uiowa.edu
Telephone: +1-319-3848001 Fax: +1-319-3536343
Received: January 10, 2015
Peer-review started: January 10, 2015
First decision: January 20, 2015
Revised: February 19, 2015
Accepted: March 30, 2015
Article in press: April 2, 2015
Published online: June 26, 2015
Processing time: 166 Days and 14.4 Hours
Abstract

Saphenous vein grafts (SVG) pseudoaneurysms, especially giant ones, are rare and occur as a late complication of coronary artery bypass grafting. This condition affects both genders and typically occurs within the sixth decade of life. The clinical presentation ranges from an asymptomatic incidental finding on imaging studies to new onset angina, dyspnea, myocardial infarction or symptoms related to compression of neighboring structures. An 82-year-old woman presented with acute onset back pain, dyspnea and was noted to have significantly engorged neck veins. In the emergency department, a chest computed tomographic angiogram with intravenous contrast revealed a ruptured giant bilobed SVG pseudoaneurysm to the right posterior descending artery (RPDA). This imaging modality also demonstrated compression of the superior vena cava (SVC) by the SVG pseudoaneurysm. Coronary angiogram with bypass study was performed to establish the patency of this graft. Endovascular coiling and embolization of the SVG to RPDA was initially considered but disfavored after the coronary angiogram revealed preserved flow from the graft to this arterial branch. After reviewing the angiogram films, a surgical strategy was favored over a percutaneous intervention with a Nitinol self-expanding stent since the latter would have not addressed the superior vena cava compression caused by the giant pseudoaneurysm. Intraoperative transesophageal echocardiogram demonstrated SVC compression by the giant pseudoaneurysm cranial lobe. Our patient underwent surgical ligation and excision of the giant pseudoaneurysm and the RPDA was regrafted successfully. In summary, saphenous vein grafts pseudoaneurysms can be life-threatening and its therapy should be guided based on the presence of mechanical complications, the patency of the affected vein graft and the involved myocardial territory viability.

Keywords: Giant saphenous graft pseudoaneurysm; Late complication of coronary artery bypass grafting; Superior vena cava syndrome; Endovascular coiling and embolization; Nitinol self-expanding stent

Core tip: Saphenous vein grafts (SVG) pseudoaneurysms, especially giant ones, are rare and occur as a late complication of coronary artery bypass grafting. Although unusual, superior vena cava (SVC) syndrome has been reported as a complication of saphenous vein graft pseudoaneurysms causing compression of the SVC. Here we report a case of such condition illustrated with state-of-the-art multi-modality images which were critical for the planning of the most appropriate treatment strategy. SVG pseudoaneurysms can be life-threatening and their therapy should be guided based on the presence of mechanical complications, the patency of the affected vein graft and the involved myocardial territory viability.