A 69-year-old man with an extensive medical history—including 2 failed renal transplants with hemodialysis, chronic immunosuppression, and coronary artery bypass grafting (CABG) 16 years previously—presented at the emergency department after sudden-onset chest pain followed by cardiopulmonary arrest. After the patient's resuscitation, a computed tomogram of his chest showed a 6.5 × 6-cm aneurysm of the saphenous vein graft (SVG) to the right coronary artery (RCA) (Fig. 1). The aneurysm actively extravasated contrast medium but was semi-contained (Fig. 2). After emergency reoperative sternotomy, the aneurysm was found to have a posterior free-wall rupture into the pericardium and right side of the chest (Fig. 3). Aneurysmectomy was performed, along with repeat CABG to the RCA because of active inferior-wall ischemia. The patient was discharged from the hospital on postoperative day 14. Six months later, he was doing very well.

Fig. 1.

Reconstructed computed tomogram (coronal view) upon the patient's presentation shows a large aneurysm of the saphenous vein bypass graft from the aorta to the right coronary artery.

Fig. 1.

Reconstructed computed tomogram (coronal view) upon the patient's presentation shows a large aneurysm of the saphenous vein bypass graft from the aorta to the right coronary artery.

Fig. 2.

Axial computed tomogram upon presentation reveals the aneurysm of the saphenous vein bypass graft from the aorta to the right coronary artery (An), a large right hemothorax (Htx), and active extravasation from the aneurysm (arrow).

Fig. 2.

Axial computed tomogram upon presentation reveals the aneurysm of the saphenous vein bypass graft from the aorta to the right coronary artery (An), a large right hemothorax (Htx), and active extravasation from the aneurysm (arrow).

Fig. 3.

Intraoperative photograph after the opening of the anterior wall of the aneurysm (An) shows a posterior free-wall rupture of the aneurysm (arrow). The suction tip is in the posterior free-wall defect.

Fig. 3.

Intraoperative photograph after the opening of the anterior wall of the aneurysm (An) shows a posterior free-wall rupture of the aneurysm (arrow). The suction tip is in the posterior free-wall defect.

Comment

Aneurysmal dilation of SVGs after CABG is a rare but known late complication. In most reports, SVG aneurysms are treated before they rupture, but there is no consensus on screening or treatment guidelines. In a review of 168 published articles (encompassing 209 patients), Ramirez and colleagues1  suggested that SVG aneurysms continue to grow and that the risk of complications increases with size. This suggests that early diagnosis and intervention are ideal; however, the natural history of these aneurysms and the risks for rupture have not been identified. In the few reports of SVG-aneurysm rupture, several patients survived to repair,2–6  so with prompt diagnosis and urgent surgical correction, aneurysmal rupture is potentially survivable. The progression of SVG aneurysms needs further evaluation if a consistent pre-rupture treatment approach is to be developed.

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Author notes

Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute, 6624 Fannin St., Suite 2480, Houston, TX 77030

From: Division of Cardiothoracic Surgery (Dr. M. Henn), Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri 63110; and Division of Cardiothoracic Surgery (Dr. L. Henn), Humility of Mary Health Partners, Saint Elizabeth's Hospital, Youngstown, Ohio 44501

This work was supported by National Institute of Health grants T32 HL007776 and RO1 HL098182-01A1.