Late development of an aneurysm of a saphenous vein used as an aortocoronary conduit

W report a case of a saphenous vein (SV) aneurysm developing late after coronary artery bypass grafting. • • • A 56-year-old man with systemic hypertension, diabetes mellitus, and hypokalemia, probably due to Liddle syndrome, was referred for unstable angina. He underwent coronary bypass at another hospital 9 years earlier (1989). At that time, he had the following grafts placed: left internal thoracic artery to the left anterior descending coronary artery, and SV to the circumflex marginal, the circumflex posterolateral, and right coronary arteries. Subsequent selective vein graft angiography after coronary bypass revealed patent grafts to the left anterior descending and the circumflex marginal arteries but occluded grafts to the circumflex posterolateral and the right coronary arteries. The patient was treated with aspirin, isosorbide dinitrate, atenolol, and captopril. Despite these medications, the control of blood pressure was not satisfactory. In 1992, after recovering from stroke, he underwent coronary arteriography for recurring angina. There was no significant progression of coronary atherosclerosis. Vein graft arteriography showed slight dilation of the circumflex marginal graft (Figure 1A). In 1995, he was hospitalized for unstable angina. Angiography now demonstrated 95% stenosis at the distal anastomosis of the left internal thoracic artery graft and the progression of dilatation with some atherosclerotic change in SV conduit to the circumflex marginal artery (Figure 1B). Percutaneous transluminal coronary angioplasty to the left internal thoracic artery graft anastomosis was successfully performed and over the next 5 years the patient remained asymptomatic. In September 1997, he again experienced exertional chest pain. In November 1997, 5 days before admission, he had severe chest pain radiating to the left shoulder. Although the chest pain was resolved by nitroglycerin and the elevation in creatine phosphokinase and troponin T were negative, electrocardiography showed persistent ST-segment depression in leads I, aVL, and V4 to V6, suggesting continuous myocardial ischemia in the lateral wall. The patient was transferred to our hospital for further treatment. Repeat selective graft angiography (Figure 1C) and 3-dimensional computed tomographic scanning (Figure 2) demonstrated a large localized dilatation, which was aneurysmal in the middle portion of the SV graft to the circumflex marginal. Two months later, the patient underwent removal of the aneurysm and bypass graft surgery. The aneurysm consisted of several hard masses, 4 to 6 cm in diameter, and arose from the left circumflex graft. These masses were filled with thrombi. The distal end of the aneurysm was occluded. Although the patient tolerated surgery well and was weaned smoothly from cardiopulmonary support, his postoperative course was complicated due to recurrent congestive heart failure which was refractory to medical therapy. The patient is still alive with restricted activity owing to chronic heart failure. • • • We report a case of a large SV aortocoronary aneurysm. Although aneurysmal dilatation of a SV graft has been reported previously,1–3 significant aneurysmal dilatation of a SV graft after coronary bypass is an unusual event.4 There was no previous report that followed the progression of the SV graft aneurysm by imaging modalities long term as in our case. Complete occlusion distal to the aneurysmal dilatation was revealed by angiography and operation further confirmed this finding. The serial selective graft angiographies suggest that progressive atherosclerosis may cause development of a large SV aortocoronary aneurysm in this case.