Br HeartJ 1993;70:189-192

Pseudoaneurysm of aortocoronary vein graftsecondary to late venous rupture: case report andliterature review

Panny Kallis, Bruce E Keogh, Michael J Davies

Department ofCardiothoracicSurgery, St George'sHospital, LondonP KallisB E KeoghDepartment ofHistopathology,St George's HospitalMedical School,LondonM J DaviesCorrespondence to:Mr P Kallis, FRCS,Deparanent ofCardiothoracic Surgery,Harefield Hospital,Harefield, MiddlesexUB9 6JH.Accepted for publication23 March 1993

AbstractFormation of pseudoaneurysms ofsaphenous vein grafts after coronaryartery bypass grafting has been reportedpreviously in relation to anastomoses orsecondary to infection. Pseudoaneurysmof the saphenous vein graft after laterupture of the saphenous vein and con-tainment by the obliterated pericabdialcavity has not been documented. Such acase is reported and published reports ofsimilar cases are reviewed.

(Br Heart J 1993;70:189-192)

True aneurysmal dilatation of the saphenousvein after myocardial revascularisation is rareand is usually secondary to atherosclerosis.'-5

Figure 1 Chest radiograph showing a 3 cm round mass overlying the left side of the mainpulmonary artery.

Formation of false aneurysm at the suturelines secondary to infection or technical errorhas also been reported.6"l Late rupture of thebody of the saphenous vein graft and contain-ment by the obliterated pericardial cavityleading to the formnation of a false aneurysmhas not been reported previously. We reportsuch a case presenting 13 years after coronaryartery bypass grafting as well as a review ofreports of other such cases. The differentmodes of presentation, possible complica-tions, -proposed mechanisms of formation,and management recommendations are dis-cussed.

Case reportA 45 year old man presented in 1977 withangina and was found to have triple vesseland mixed aortic valve disease. He underwentquadruple coronary artery- bypass graftingwith a reversed saphenous vein, which wasnoted to be of good quality and calibre at thetime. His aortic valve was replaced with a 25mm Carpentier-Edwards xenograft and themitral valve was noted to be normal. Threeweeks later he developed Staphylococcus epi-dermidis endocarditis which resulted in emer-gency reoperation for severe aorticregurgitation. The valve had becomedetached from the non-coronary sinus and itwas replaced with a 2-4 cm fresh homograft.Two days after the operation, after a respira-tory arrest, the patient underwent emergencytracheostomy and insertion of a left chestdrain for pneumothorax. An emergency tho-racotomy was also performed for bleedingfrom the chest drain. Six weeks later he wasdischarged home apyrexial with a normalwhite cell count.Ten years later he developed dyspnoea on

minimal exertion and cardiac catheterisationconfirmed severe aortic regurgitation. All fourvein grafts were patent, with some atheroma,but with neither critical stenoses nor aneurys-mal dilatation. He underwent aortic valvereplacement for perforation of the left coro-nary cusp of the homograft with a size 9AStarr-Edwards prosthesis.

Three years later, at the age of 58, he onceagain presented with dyspnoea on exertionand was noted to have severe aortic regurgita-tion. His chest radiograph showed a smallmass overlying the left side of the pulmonaryartery (fig 1), which was not evident on chestradiographs for the first year after his previousoperation. A computed tomogram confirmneda 3 cm mass on the left side of the pulmonary

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Figure 2 Computedtomtiogramn of the thoraxshowitng a 3 cm massadjacent to the mainpulml)onaty artery.

artery (fig 2). Cardiac catheterisation showedsevere aortic regurgitation and criticalstenoses of the vein grafts to the right, the leftanterior descending, and diagonal coronaryarteries. Angiography of the vein graft to theobtuse marginal branch of the circumflexartery had shown a saccular aneurysm but nocritical stenosis (fig 3).

At operation the aortic prosthesis wasfound to have partially dehisced and wasreplaced with a size 1 1A Starr-Edwards valvewith concomitant triple coronary arterybypass grafts. The aneurysmal part of thevein graft was resected after proximal and dis-tal ligation. After operation he requiredinotropic support and intra aortic ballooncounterpulsation but died 24 hours later from

Figure 3 Preoperativecoronary angiogramshowing a saccularaneurysm of the saphenousvein graft.

low cardiac output.Histopathological examination of the

saphenous vein graft showed complete rup-ture of the intima and media with the rup-tured ends folded back (figs 4 and 5). Thiswas contained by the obliterated pericardialcavity and a 2 cm false aneurysm of the bodyof the saphenous vein graft was formed thatcontained thrombus. Microscopy of the veingraft at other sites showed some intimal ath-erosclerosis.

DiscussionIn 1968 Dedominico and colleagues'2 report-ed the development of aneurysms in externaljugular veins used in experimental coronaryartery bypass grafting in dogs five years afterimplantation. Despite this finding it was ini-tially postulated that aneurysmal dilatationwould not occur in the thicker walled humansaphenous veins. This was confirmed byDarling et aP3 in an angiographic studyof saphenous veins used for 295femoropopliteal bypass grafts that onlyshowed five anastomotic pseudoaneurysms.Later communications, however, reported thesporadic occurrence of aneurysms of thesaphenous vein after carotid'4 and femoro-popliteal bypass surgery.'5"16 SubsequentlyRiahi and colleagues first reported aneurys-mal dilatation of a coronary saphenous veingraft in 19751 although these remain rare.Most are pseudoaneurysms occurring at anas-tomotic sites (table 1) but true aneurysmswithin the body of the saphenous vein graftcan also occur (table 2). Multiple aneurysmsof a single vein graft have also been reported35 20 but their relation with pre-existing varicoseveins is unknown. Failure to reverse thesaphenous vein at the time of graftng hasbeen proposed as a possible cause of multipleaneurysms.3The mechanisms of formation remain

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Pseudoaneurysm of aortocoronary vein graft secondary to late venous rupture: case report and literature review

Media ofvein graft

Figure 4 Drawing ofa cross section of the anthe saphenous vein graft showing complete ruptintima and media of the vein with the rupturesback (A and B). The sac of the pseudoaneuryscontaining thrombus is also shown.

unclear but the following causatiNhave been postulated: hypertensiorto the vein at the time of operatnecrosis, weakness at a branch site,in the area of valves secondary to acircular muscle in the media, coroisecondary to a fistula, thrombosis, a

rotic change within the graft, mycotitis, and dissection of the saphenous(tables 1 and 2). Several factors seea part in the formation of saphexgraft aneurysms which may occur a12 days17 or as late as 17 years after

The early aneurysms are more likely to befalse and due to infection or operative factors,whereas those of late onset are more likely to

Medial tear

be due to atherosclerosis especially in patientswith hyperlipidaemia.20Our case shows a new mechanism of for-

mation of a saphenous vein graft aneurysm.Rupture of the vein graft must have occurredone to three years after the third operationbecause there was no preoperative angio-graphic evidence of aneurysmal dilatation.Furthermore serial chest radiographs afteroperation for the first year did not show the

Thrombus in aneurysm overlying the pulmonary artery asaneurysm sac shown two years later (figs 1 and 2). Late

eurysm of rupture (11-13 years) of the body of theture of the saphenous vein graft into the pericardial cavi-ends folded ty was contained, as a result of adhesions

from the previous three operations, leading toformation of a false aneurysm. The fact thatthe pericardial cavity was obliterated also pre-

te factors vented fatal haemorrhage or cardiac tampon-1, trauma ade. The most plausible mechanism oftion, vein rupture of the saphenous vein graft is weak-weakness ness of the wall of the vein secondary to ath-bsence of erosclerotic changes.nary steal Saphenous vein graft aneurysms can pre-theroscle- sent in a variety of ways such as a large medi-ic vasculi- astinal mass 821 or as an enlarging pulsatilevein graft mass over the xiphoid.19 The reported com-m to play plications include rupture,722 symptomaticaous vein coronary embolisation,2' fatal dehiscence sec-ts early as ondary to bacterial infection,17 and formationsurgery.16 of a fistula between the vein graft and the

Figure 5 Microscopicalexamination of the twoends of the ruptured media(A and B in fig 4).Stained with elastic-vanGieson, magnificationoriginally x 40.

Table 1 False coronary vein graft aneurysms

Authors Time Mode ofpresentation Management Outcome Postulated mechanism

Shapeero et al 6 9 yr Myocardial infarction, Coil occlusion Survivedmediastinal mass, rupture

Yousem et al ' 5 yr Mediastinal mass, rupture Conservative Died VasculitisKazui et al8 2-4 yr Recurrent angina Resection and CABG Survived Trauma at operation

2 patientsSherry et al 9 13-15 yr Recurrent angina

2 patientsDe Haan et al 10 A few days Routine early angiogram Resection and CABG Survived Tear of stitches at distal anastomosesDucksoo et al 9 yr Myocardial infarction, Coil occlusion Survived

mediastinal massDouglas et al 17 12 days Rupture of proximal Emergency reoperation Died Mediastinitis

anastomosis and control of bleedingForster et al 18 17 yr Large mediastinal mass ResectionSmith and Goldstein9 2 months Pulsatile mass over xiphoid Resection Survived Mediastinitis

CABG, coronary artery bypass grafting.

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Table 2 True coronary vein graft aneurysms

Authors Time Mode ofpresentation Management Outcome Postulated mechanism

Riahi et alt 6 months Aortic regurgitation Resection and CABG SurvivedPintar et al 2 5-6 yr Recurrent angina Resection and CABG Survived Atherosclerotic

2 patientsBenchimol et al3 3 months Symptom free, multiple Conservative Survived Failure to reverse vein,

muscle weakness near valvesBramlet et al 5 yr Unstable angina Conservative Died Dissection of body of SVG,

hypertension, trauma, necrosisILang et al 5 6-10 yr Recurrent angina, Resection and CABG - Atherosclerotic (4)

5 patients multiple aneurysms dissection ofbody ofSVG (1)Teja et al 20 14 yr necropsy, - Died Atherosclerotic

multiple aneurysmsLopez Velardo et al 21 15 yr Large mediastinal mass Resection Died AtheroscleroticMurphy et al 22 14 yr Rupture, Resection Survived

large haemothoraxTalierco et al 23 9 yr Symptomatic coronary Resection and CABG Survived

embolisationRiahi et al 4 10 yr Fistula between Resection, CABG, Died Atherosclerotic

SVG and RV and closure of fistulaDzavic et al25 13 yr Myocardial infarction Conservative Died

CABG, coronary artery bypass grafting; RV, right ventricle; SVG, saphenous vein graft.

right ventricle.24As most aneurysms of saphenous vein

grafts remain undiscovered their true inci-dence and natural time course are likely toremain unknown. As a result it is difficult toformulate rigid management policies for thispathology but some guidelines can be put for-ward in the light of reported cases. In thepresence of another cardiac pathology requir-ing surgical intervention the aneurysm shouldbe resected at the same time even if there isno restriction to flow in the vein graftinvolved. Although successful coil occlusiontreatment for controlling haemorrhage froman aneurysm of the saphenous vein graft hasbeen reported,611 surgery remains the treat-ment of choice for the complicatedaneurysms. Because of the likelihood of com-plications (tables 1 and 2) a large aneurysmwith a patent vein graft shou4d probably beconsidered for resection and replacementwith another graft. It is difficult to proposeclear recommendations regarding the man-agement of small symptom free aneurysmsdiscovered coincidentally, but they should atleast be observed for changes in size andcomplications. This has been successfullyperformed by non-invasive methods such ascomputed tomography,67 magnetic resonanceimaging,9 and transoesophageal echocardiog-raphy.25 It is even more difficult to know whatshould be done with the aneurysmal veingraft that has already occluded distal to theaneurysm, but probably it should be followedup with non-invasive imaging.

Although aneurysmal dilatations of saphe-nous vein grafts have been previously report-ed this is, to our knowledge, the first reportedcase of false aneurysm formation after laterupture of the body of the vein graft.We thank Mr D J Parker for his useful contribution in writingthis paper.

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3 Benchimol A, Harris CL, Desser KB, Fleming H.Aneurysms of an aortocoronary artery saphenous veinbypass graft-A case report. Vasc Surg 1975;9:261-4.

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5 Liang BT, Antman EM, Taus R, Collins JJ, Schoen FJ.Atherosclerotic aneurysms of aortocoronary vein grafts.Am Y Cardiol 1988;61:185-8.

6 Shapeero LG, Guthaner DF, Swerdlow CD, Wexler L.Rupture of a coronary bypass graft aneurysm: CT evalu-ation and coil occlusion therapy. AJR Am J Roentgenol1983;141: 1060-2.

7 Yousem D, Scott WJr, Fishman EK, Watson AJ, Traill T,Gimenez L. Saphenous vein graft aneurysms demon-strated by computed tomography. J Comput AssistTomogr 1986;3:526-8.

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10 De Haan HPJ, Huysmans HA, Weeda HWH, Bosker HA,Buis B. Anastomotic pseudoaneurysm after aortocoro-nary bypass grafting. Thorac Cardiovasc Surg 1985;33:55-6.

11 Ducksoo K, Guthaner DF, Wexler L. Transcatheterembolisation of a leaking pseudoaneurysm of saphenousvein aortocoronary bypass graft. Cathet Cardiovasc Diagn1983;9:591-4.

12 Dedominico M, Sameh AA, Berger K, Wood SJ, SauvageLR. Experimental coronary artery surgery. Long termfollow up, bypass venous autografts, longitudinal arteri-otomies, and end to end anastomoses. J ThoracCardiovasc Surg 1968;56:617-23.

13 Darling RC, Linton RR, Razzuk MA. Saphenous veinbypass grafts for femoropopliteal occlusive disease: reap-praisal. Surgery 1967;61:31-40.

14 Carrasquilla C, Weaver AW. Aneurysm of saphenous veingrafts to the common carotid artery. Vasc Surg1972;6:66-8.

15 De La Rocha AG, Peixoto RS, Baird RJ. Atherosclerosisand aneurysm formation in a saphenous vein graft. BrJSurg 1973;60:72-3.

16 Davidson ED, DePalma RG. Atherosclerotic aneurysmoccurring in an autogenous vein graft. Am J Surg 1972;124:112-4.

17 Douglas BP, Buikley BH, Hutchins GM. Infected saphe-nous vein coronary artery bypass graft with mycoticaneurysm. Fatal dehiscence of the proximal anastomo-SiS. Chest 1979;75:76-7.

18 Forster DA, Haupert MS. Large mediastinal mass sec-ondary to an aortocoronary saphenous vein bypass graftaneurysm. Ann Thorac Surg 1991;52:547-8.

19 Smith JA, Goldstein J. Saphenous vein graft pseudo-aneurysm formation after postoperative mediastinitis.Ann Thorac Surg 1992;54:766-8.

20 Teja K, Dillingham R, Mentzer RM. Saphenous veinaneurysms after aortocoronary bypass grafting:Postoperative interval and hyperlipidemia as determin-ing factors. Am Hearty 1987;113:1527-9.

21 Lopez-Velarde P, Hallman GL, Treistman B. Aneurysmof an aortocoronary saphenous vein bypass graft pre-senting as an anterior mediastinal mass. Ann ThoracSurg 1988;46:349-50.

22 Murphy JPJr, Shabb B, Nishikawa A, Adams PR, WalkerWE. Rupture of an aortocoronary saphenous vein graftaneurysm. AmY Cardiol 1986;58:555-7.

23 Taliercio CP, Smith HC, Pluth JR, Gibbons RJ. Coronaryartery venous bypass graft aneurysm with symptomaticcoronary artery emboli. JAm Coil Cardiol 1986;7:435-7.

24 Riahi M, Stone KS, Hanni CL, Fierens E, Dean RE.Right ventricular-saphenous vein graft fistula: unusualcomplication of aortocoronary bypass grafting. J ThoracCardiovasc Surg 1984;87:626-8.

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