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

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Overview

Pathophysiology

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

Indications for CABG

Prognosis

Diagnosis

Imaging in the Patient Undergoing CABG

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Pulmonary Artery Catheterization
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Surgical Procedure

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Intervention in left main coronary artery disease
The Traditional Coronary Artery Bypass Grafting Procedure (Simplified)
Minimally Invasive CABG
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Conduits Used for Bypass
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Pharmacotherapy in patients undergoing CABG CABG

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Anomalous Coronary Arteries
COPD/Respiratory Insufficiency
Existing Renal Disease
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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.

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