Coronary artery bypass surgery other non-atherosclerotic saphenous vein graft diseases

Jump to: navigation, search

Coronary Artery Bypass Surgery Microchapters

Home

Patient Information

Overview

Pathophysiology

Saphenous Vein Graft Disease
Other Non-Atherosclerotic Saphenous Vein Graft Diseases

Indications for CABG

Prognosis

Diagnosis

Imaging in the Patient Undergoing CABG

Chest X Ray

Angiography

CT Angiography
MRI Angiography

Trans-Esophageal Echocardiography

Treatment

Goals of Treatment

Perioperative Management

Perioperative Monitoring

Electrocardiographic Monitoring
Pulmonary Artery Catheterization
Central Nervous System Monitoring

Surgical Procedure

Anesthetic Considerations
Intervention in left main coronary artery disease
The Traditional Coronary Artery Bypass Grafting Procedure (Simplified)
Minimally Invasive CABG
Hybrid coronary revascularization
Conduits Used for Bypass
Videos on Spahenous Vein Graft Harvesting
Videos on Coronary Artery Bypass Surgery

Post-Operative Care and Complications

Recommendation for Duration of DAPT in Patients With ACS Treated With CABG

Special Scenarios

Anomalous Coronary Arteries
COPD/Respiratory Insufficiency
Existing Renal Disease
Concomitant Valvular Disease
Previous Cardiac Surgery
Menopause
Carotid Disease evaluation before surgery

Coronary artery bypass surgery other non-atherosclerotic saphenous vein graft diseases On the Web

Most recent articles

Most cited articles

Review articles

CME programs

powerpoint slides

Images

Ongoing trials at clinical trials.gov

US National guidelines clearinghouse

NICE guidance

FDA on Coronary artery bypass surgery other non-atherosclerotic saphenous vein graft diseases

CDC on Coronary artery bypass surgery other non-atherosclerotic saphenous vein graft diseases

Coronary artery bypass surgery other non-atherosclerotic saphenous vein graft diseases in the news

Blogs on Coronary artery bypass surgery other non-atherosclerotic saphenous vein graft diseases|-

Directions to Hospitals Performing Coronary artery bypass surgery other non-atherosclerotic saphenous vein graft diseases

Risk calculators for Coronary artery bypass surgery other non-atherosclerotic saphenous vein graft diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Mohammed A. Sbeih, M.D.[3]

Other non-atherosclerotic saphenous vein graft diseases

Saphenous vein graft aneurysms

This disease process is also known as SVGA, aortocoronary saphenous vein graft aneurysms, saphenous vein graft aneurysm disease and saphenous vein graft aneurysmal dilatation and is defined as a local dilation of the vessel more than 1.5 X the adjacent reference segment. The aneurysms can be up to 14 cm in diameter.

Classification

  • True aneurysms: All 3 layers of the vessel wall are involved
  • Pseudoaneurysms: There is disruption of 1 or more layers of the vessel wall.

Epidemiology and demographics

Over the course f a SVGs 7 year lifetime, the risk of aneurysm development is 14%. True aneurysms outnumber false ones by a ratio of 2:1.

Pathophysiology

Causes of saphenous vein graft aneurysms include the following:

Natural history and complications

SVGAs can rupture which is associated with a high rate of morbidity and even mortality. They can also be a nidus for embolization.

Diagnosis

History

If a patient with a history of CABG develops chest pain and has a mediastinal mass, an SVGA should be suspected.

The majority of patients are asymptomatic with a true aneurysm, and most often the SVGA is an incidental finding on an imaging study. If the patient is symptomatic, about half the time it presents as an acute coronary syndrome. Very rarely tamponade from compression of the right atrium or ischemia due to compression of the left internal mammary artery bypass graft has been observed.

In contrast to true aneurysms, patients with false aneurysms are symptomatic in 85% of cases. About two thirds of the time they present with an acute coronary syndrome. If a patient with an SVGA does present with chest pain or hemoptysis, it may be due to the formation of a fistula.

Physical examination

Rarely on physical examination a murmur will be auscultated or cutaneous bleeding will be observed (both due to a fistula).

Imaging

SVGA can be definitively diagnosed on either coronary angiography or CT angiography. On occasion, an SVGA can be observed as either hilar or mediastinal mass on chest x ray.

Management

Pharmacologic management consists of aspirin and lipid-lowering therapy. The benefit if any of coumadin and beta-blockers is not known.

A surgery or a percutaneous intervention is suggested if:

  • A pseudoaneurysm is present
  • The aneurysm is more than 2 cm greater than the adjacent vessel
  • A fistula is present (surgery, coiling, or stenting)
  • If the aneurysm is mycctic (surgery)
Surgery

There are multiple surgical approaches to repairing an aneurysm:

  • Ligate the aneurysm-containing SVG and place a new SVG.
  • Resect the aneurysmal portion of the diseased graft and sew a new SVG segment in in an end-to-end fashion
  • Ligate the old SVG without revascularization
  • Evacuate the hematoma and repair the SVG with a venous patch graft.
Percutaneous intervention

In the past, percutaneous intervention was reserved for patients who were too sick to undergo surgery. However, due to the improved tools that are available, more patients are undergoing percutaneous intervention as described below:

  • Coil embolization: This technique has evolved so that a stent excludes the coil form lying in the lumen of the SVG.
  • Covered stents: The JOSTENT Coronary Stent Graft (Abbott Vascular, Redwood City, Calif) can be used to exclude the aneurysm form the body of the SVG. The device is made up of an ultra-thin layer of polytetrafluoroethylene (PTFE).
  • Multiple overlapping stents can be used to exclude the aneurysm.

Amyloidosis of saphenous coronary bypass grafts

Amyloid has been associated with accelarated disease in saphenous vein grafts.[1] [2] [3] [4] [5]

Rupture of the saphenous vein coronary artery bypass grafts

Aspergillus species causing a necrotizing vasculitis have been associated with rupture of a saphenous vein grafts.

References

  1. Marti MC, Bouchardy B, Cox JN. Aortocoronary bypass with autogenous saphenous vein grafts: histopathological aspects. Virchows Arch Abt A Path Anat 1971; 352: 255–66.
  2. Garrett HE, Dennis EW, DeBakey ME. Aortocoronary bypass with saphenous vein graft. JAMA 1973; 223: 792–4.
  3. Zemva A, Ferluga D, Zorc M, Popovic M, Porenta OV, Radovanovic N. Amyloidosis in saphenous vein aortocoronary bypass grafts. J Cardiovasc Surg 1990; 31: 441–4.
  4. Salerno TA, Wasan SM, Charrette EJ. Prospective analysis of heart biopsies in coronary artery surgery. Ann Thorac Surg 1979; 28: 436–9.
  5. Pelosi F, Capehart J, Roberts WC. Effectiveness of cardiac transplantation for primary (AL) cardiac amyloidosis. Am J Cardiol 1997; 79: 532–5.