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J Thorac Cardiovasc Surg 2007;134:230-232
© 2007 The American Association for Thoracic Surgery
Brief Communication |
a Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière, Paris, France
b Department of Radiology, Groupe Hospitalier Pitié-Salpétrière, Paris, France.
Received for publication January 21, 2007; revisions received February 6, 2007; accepted for publication February 19, 2007. * Address for reprints: Fabien Koskas, MD, PhD, Service de Chirurgie Vasculaire, Groupe hospitalier Pitié-Salpétrière, 47-83 Boulevard de l’Hôpital 75651 Paris Cedex 13. (Email: fabien.koskas{at}psl.ap-hop-paris.fr).
Aneurysms and pseudoaneurysms complicating aorta–coronary bypasses with the saphenous vein are a rare but possibly underestimated complication. Riahi and associates1
reported the first case in 1975. We report the first case of a saphenous bypass pseudoaneurysm treated with a homemade endograft in the ascending aorta.
A 78-year-old man was referred to our hospital with an enlarging left hilar mass found on a routine chest x-ray film. His medical history included chronic renal insufficiency with dialysis, chronic heart failure, aorta–bifemoral bypass, and double aorta–coronary bypass grafting 17 years ago. He had undergone a pedicled left internal thoracic artery graft to the left anterior descending artery and a reversed saphenous vein graft to the first obtuse marginal branch. Since that time, the patient had remained free of symptoms.
On examination, the patient was afebrile with stable hemodynamics. He did not have any cardiac or pulmonary symptoms.
A computed tomographic scan revealed a 75-mm proximal pseudoaneurysm resulting from a disruption of the aortic anastomosis (Figure 1, A). Cardiac catheterization showed a saccular dilatation of the saphenous vein graft. The bypass graft was occluded distal to the dilatation. The left internal thoracic artery graft was still patent (Figure 1, B).
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Nine days after admission, a covered endograft was positioned in the ascending aorta.
Our endograft was a homemade device built according to the method that we described earlier.2 In brief, the Gianturco arterial Z stent is an auto-expandable stainless steel structure (316L) made of a circular wire plied in a zigzag pattern (W. Cook Europe, Bjaeverskov, Denmark). Two Gianturco arterial Z stents were assembled with polyester ligatures (Cardioflon; Laboratoires Péters, Bobigny, France) and placed in a tube of uncrimped woven polyester (Twillweave; Vascutek, Incchinnan, Scotland) with a diameter of 36 mm. The right common carotid artery was exposed through a transverse incision and punctured. Through the needle, a J-tipped 0.35-inch guide wire was pushed into the aorta under fluoroscopy. A 5F sheath was then pushed over the wire. An Amplatz Superstiff guide wire (Boston Scientific, Natick, Mass) was then pushed into the sheath. Heparin, 1 mg/kg, was given intravenously. Through a transverse arteriotomy centered by the puncture site, a 22F introducer (Keller-Timmermans; W. Cook Europe, Bjaeverskov, Denmark) was placed under fluoroscopic control over the guide into the ascending aorta. The endograft loaded into this introducer was then deployed by retraction of the sheath of this latter over its pusher.
The postoperative course was simple. No electrocardiographic change was noticed. Postprocedure cardiac enzymes were negative. On the fourth postoperative day, computed tomography confirmed the total exclusion of the pseudoaneurysm and the good position of the endograft (Figure 2). The patient was discharged on the sixth postoperative day.
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This case demonstrates that selected cases of proximal aneurysm or pseudoaneurysm complicating coronary bypass with the saphenous vein are amenable to endovascular repair with endografts.
Severe dilatations complicating aorta–coronary bypass with the saphenous vein must be treated because of their potential complications, such as rupture and distal embolization.
These dilatations often occur in old and polypathologic patients. Moreover, when a surgical treatment is decided, redo surgery can be difficult and hazardous because of adhesions. Considering these problems, endovascular treatment was proposed in this indication. It was first described by Shapeero and associates3 in 1983. They treated a midgraft dilatation with occlusion therapy using coils. To our knowledge, 11 other cases of endovascular procedures have reported with good results. Several endovascular procedures have been used, such as coil occlusion therapy, covered stent in the saphenous vein graft,4 and Amplatzer vascular plug.5
In these cases, endovascular repair was performed only for body or distal saphenous vein graft dilatations.
In our case, conventional repair was not performed because of the patient’s health status. As has been suggested for abdominal and thoracic aortic aneurysm, endografts could decrease morbidity and mortality in high-risk surgical patients. An endovascular procedure using an ascending aortic endograft seemed to be a reasonable option to exclude the pseudoaneurysm.
No suitable endograft was commercially available in our national market. The use of a commercially available endograft would have necessitated covering the supra-aortic trunks. We therefore preferred to use a specially tailored homemade endograft.2
To our knowledge, our case is the first of a saphenous vein graft dilatation treated with an ascending aortic endograft.
References
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