Abstract
We report the case of a 72-year-old man admitted to our hospital for chest pain. He had undergone coronary artery bypass graft surgery 23 years before. Contrast-enhanced computer tomography revealed a severe double-lobed dilatation of the saphenous vein graft for the obtuse marginal branch. Coronary angiography did not opacify completely the saphenous vein graft for the huge turbulence in the dilatation. Severe saphenous vein graft dilatation have a significant mortality and it has been generally treated by surgical repair, such as resection with or without bypass of the affected territory. We described an interventional technique, named “ double-layer bridging ” that combines metallic DES and covered stent used in a double layer. This percutaneous technique, relatively simple and virtually usable for any type of severe dilatation independently of length, can be a reasonable and safe option to exclude giant aneurysm and maintaining distal flow.
1
Introduction
Severe saphenous vein graft (SVG) dilatation is an unusual complication of coronary artery bypass grafting (CABG) with an overall incidence of <1% [ ]. Most authors refer to this condition as an aneurysm or pseudoaneurysm even when there is not pathological tissue characterization. Aneurysm is defined as a localized dilation of blood vessel which contains the entire vessel wall, whereas pseudoaneurysm is a rupture in the vascular wall leading to an extravascular hematoma that freely communicates with the intravascular space [ ]. Without pathological tissue it is difficult to differentiate them, therefore it is recommended the term severe SVG dilation. It occurs usually >10 years after bypass surgery, can measure until 6.0 ± 3.0 cm at the time of diagnosis and it could be cause of compression on cardiac and vascular structures with potential catastrophic effects due to its rupture. Severe SVG dilatation may be found in asymptomatic patients at routine follow-up or it may reveal as chest pain, dyspnea or fever. The hospital mortality in symptomatic patient was reported to be higher than 15% [ ], the optimal treatment of this uncommon condition is still debated [ ].
2
Case presentation
A 72 year-old man arrived to our hospital with acute chest pain from 12 h. Twenty-three years before he had undergone CABG with left internal mammary artery (LIMA) to left anterior descending (LAD), SVG to posterior descending (SVG-PD) and obtuse marginal branch (SVG-OM). A Fast-Echo detected a mild pericardial effusion, left ventricle wall motion and aortic root dimensions were normal. Contrast-enhanced computer tomography (CT), done to rule out aortic dissection, identified a severe double-lobed dilatation of the SVG-OM ( Fig. 1 ). The two lobes were similar in dimension (5.8 × 6.0 cm the diameters of the bigger and 4.5 × 5.8 cm of the minor) joined by a long neck of 8 cm in length. The lumen of the vascular malformation was partially occupied by thrombus with an area of suspected rupture of the wall ( Fig. 1 ). Furthermore, a mild hemopericardium and a slight compression on right ventricle by the vascular malformation were observed. CT revealed an abdominal aortic aneurysm with a diameter of 5.0 cm. An urgent invasive coronary angiography (ICA) showed a severe disease of native vessels ( Fig. 2 ): a chronic total occlusion (CTO) of proximal LAD, a CTO of proximal circumflex and a CTO of mid right coronary artery; finally the patency of the LIMA to LAD and the occlusion of the SVG-PD, while it was not possible to opacify completely the SVG-OM for the presence of a huge turbulence in the dilated graft (online Video 1 ). After heart team discussion cardiac surgery was excluded for the prohibitive risk of a re-sternotomy with SVG-OM dilatation rupture, so a strategy of percutaneous intervention was preferred. We accordingly decided to exclude the dilatation using two different layers of overlapping stents. An external layer of multiple metallic drug eluting stents (DES) would have provided the support for the inner layer of multiple covered stents which would have definitively sealed the lumen of the graft. We defined this technique “ double-layer bridging ”. By right femoral access the SVG-OM was intubated with a 7 fr. AL 2 guiding catheter; a floppy wire (Runtrough 0,014″ 180 CM, Terumo, Shibuya, Tokyo, Japan) supported by over-the-wire (OTW) catheter (Ryujin plus 1,5 mm × 15 mm, Terumo, Shibuya, Tokyo, Japan) was advanced distally in the graft using only fluoroscopy for the difficulty to opacify the graft with contrast. To ensure the correct position of the wire in the distal vessel we injected contrast with the OTW catheter to visualize the distality of the graft and the marginal branch down the dilatation. Finally the right position of the wire in the vessel was confirmed also by IVUS ( Fig. 3 ). At this point, floppy wire was changed with an high support guidewire (Ironman 0.014″–300 cm, Abbott Vascular, Temecula, California) and using TRAP technique the OTW catheter was removed. In the first step of our “ double-layer bridging ” a new body of the SVG-OM pseudo-aneurysm was reconstructed using four 5.0/26 mm Resolute ONYX (Medtronic, Minneapolis, Minnesota). The stents were implanted starting from distal segment to proximal segment with a wide overlap: one third of every stent was imbricate with one third of the stent previous implanted ( Fig. 4 ) to ensure stability of the new bridge (online Video 2 ). In the second step, four 4.8/26 mm Graftmaster polytetrafluoroethylene covered stent (Abbott Vascular, Temecula, California) were implanted with minimal overlap to complete the second layer of the bridge. A final dilation with a non-compliant balloon (5.0 mm/20 atm) ended the interventional procedure. IVUS showed the optimal expansion of stents in all covered segment ( Fig. 5 ). Final angiography revealed the complete exclusion of the dilatation with a full patency of the SVG-OM ( Fig. 6 , online Video 3 ). The procedure and hospitalization were free of events and the patient was discharged after 7 days with a dual antiplatelet therapy composed by aspirin and clopidogrel. At one year of follow up the patient was alive and free of symptoms. A control CT showed the full patency of the double-layer covered segment of SVG-OM with the complete thrombosis of the dilatation ( Fig. 7 ).
2
Case presentation
A 72 year-old man arrived to our hospital with acute chest pain from 12 h. Twenty-three years before he had undergone CABG with left internal mammary artery (LIMA) to left anterior descending (LAD), SVG to posterior descending (SVG-PD) and obtuse marginal branch (SVG-OM). A Fast-Echo detected a mild pericardial effusion, left ventricle wall motion and aortic root dimensions were normal. Contrast-enhanced computer tomography (CT), done to rule out aortic dissection, identified a severe double-lobed dilatation of the SVG-OM ( Fig. 1 ). The two lobes were similar in dimension (5.8 × 6.0 cm the diameters of the bigger and 4.5 × 5.8 cm of the minor) joined by a long neck of 8 cm in length. The lumen of the vascular malformation was partially occupied by thrombus with an area of suspected rupture of the wall ( Fig. 1 ). Furthermore, a mild hemopericardium and a slight compression on right ventricle by the vascular malformation were observed. CT revealed an abdominal aortic aneurysm with a diameter of 5.0 cm. An urgent invasive coronary angiography (ICA) showed a severe disease of native vessels ( Fig. 2 ): a chronic total occlusion (CTO) of proximal LAD, a CTO of proximal circumflex and a CTO of mid right coronary artery; finally the patency of the LIMA to LAD and the occlusion of the SVG-PD, while it was not possible to opacify completely the SVG-OM for the presence of a huge turbulence in the dilated graft (online Video 1 ). After heart team discussion cardiac surgery was excluded for the prohibitive risk of a re-sternotomy with SVG-OM dilatation rupture, so a strategy of percutaneous intervention was preferred. We accordingly decided to exclude the dilatation using two different layers of overlapping stents. An external layer of multiple metallic drug eluting stents (DES) would have provided the support for the inner layer of multiple covered stents which would have definitively sealed the lumen of the graft. We defined this technique “ double-layer bridging ”. By right femoral access the SVG-OM was intubated with a 7 fr. AL 2 guiding catheter; a floppy wire (Runtrough 0,014″ 180 CM, Terumo, Shibuya, Tokyo, Japan) supported by over-the-wire (OTW) catheter (Ryujin plus 1,5 mm × 15 mm, Terumo, Shibuya, Tokyo, Japan) was advanced distally in the graft using only fluoroscopy for the difficulty to opacify the graft with contrast. To ensure the correct position of the wire in the distal vessel we injected contrast with the OTW catheter to visualize the distality of the graft and the marginal branch down the dilatation. Finally the right position of the wire in the vessel was confirmed also by IVUS ( Fig. 3 ). At this point, floppy wire was changed with an high support guidewire (Ironman 0.014″–300 cm, Abbott Vascular, Temecula, California) and using TRAP technique the OTW catheter was removed. In the first step of our “ double-layer bridging ” a new body of the SVG-OM pseudo-aneurysm was reconstructed using four 5.0/26 mm Resolute ONYX (Medtronic, Minneapolis, Minnesota). The stents were implanted starting from distal segment to proximal segment with a wide overlap: one third of every stent was imbricate with one third of the stent previous implanted ( Fig. 4 ) to ensure stability of the new bridge (online Video 2 ). In the second step, four 4.8/26 mm Graftmaster polytetrafluoroethylene covered stent (Abbott Vascular, Temecula, California) were implanted with minimal overlap to complete the second layer of the bridge. A final dilation with a non-compliant balloon (5.0 mm/20 atm) ended the interventional procedure. IVUS showed the optimal expansion of stents in all covered segment ( Fig. 5 ). Final angiography revealed the complete exclusion of the dilatation with a full patency of the SVG-OM ( Fig. 6 , online Video 3 ). The procedure and hospitalization were free of events and the patient was discharged after 7 days with a dual antiplatelet therapy composed by aspirin and clopidogrel. At one year of follow up the patient was alive and free of symptoms. A control CT showed the full patency of the double-layer covered segment of SVG-OM with the complete thrombosis of the dilatation ( Fig. 7 ).
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