Percutaneous Closure of a Coronary Artery-to-Vein Graft Anastomotic Pseudoaneurysm Presenting as Acute Coronary Syndrome after Recent Coronary Artery Bypass Grafting

Abstract

Pseudoaneurysm formation has been reported in degenerated coronaryP seudoaneurysms of degenerated saphenous vein grafts (SVGs) can form after coronary artery bypass grafting (CABG).1 Pseudoaneurysm formation at the distal anastomotic site after CABG is very rare, and the clinical presentation and treatment of this phenomenon have not been well described. We present the case of a recent CABG patient whose pseudoaneurysm at the coronary artery-SVG anastomosis was treated by means of percutaneous coil embolization. In addition, we discuss other management options. Case ReportIn December 2012, a 63yearold man presented at another hospital with syncope and a nonSTsegmentelevation myocardial infarction (NSTEMI), a peak troponin I level of 11.4 ng/mL, and associated new Twave inversions in the inferior electro cardiographic leads. He had undergone 4vessel, onpump CABG 4 weeks earlier: a graft of the left internal mammary artery to the left anterior descending coronary artery, a saphenous vein graft to the right posterior descending artery, and a saphenous vein Y graft to a superior branch of the ramus intermedius (RI) and the first diagonal branch. A quantitative coronary angiogram showed a 1.7 × 1.5cm pseudoaneurysm that appeared to arise from the SVG-RI anastomotic site (Fig. 1A). Even though the pseudoaneurysm filled after angiographic contrastmedium injection from both the left main coronary artery (LMCA) and the SVG, the filling was substantially more pronounced when injections were made from the SVG (Fig. 1B). The other bypass grafts were patent, and no new obstructive native coronary artery lesions were apparent. It was presumed that the patient's NSTEMI was secondary to the pseudo aneurysm-most likely from distal embolization of intraluminal thrombus from the pseudoaneurysm, even though no distal cutoff or other angiographic evidence of embolization was noted. Another possible mechanism by which the pseudoaneurysm could cause acute coronary syndrome (ACS) was mass effect; however, no compres sion of the adjacent vessels was seen. The patient was referred to our center for further Case Reports

Post Traumatic Pseudoaneurysm of Left Anterior Descending Artery Presenting as Acute Coronary Syndrome

“…Coronary artery aneurysms can be managed successfully by using PTFE-coated stents or autologous vein grafts for large proximal vessels, provided that the stents can be delivered to the site [22, 23]. Percutaneous coil embolization has often been used for coronary artery false aneurysms [22] and coronary perforation [24].…”

Just Another Acute Chest Pain? Case of Contained Rupture of a Saphenous Venous Graft Pseudo-Aneurysm Mimicking Acute Coronary Syndrome

“…Open surgical exploration with re-do sternotomy is the most common therapy of choice due to its definitive treatment with direct repair of the pseudo-aneurysm, but coil embolization [12], covered stenting [13], thrombin injection, Amplatzer device placement and conservative management [14] have all been used in the management of SVG pseudoaneurysms. To date, literature on SVG pseudo-aneurysm is limited to case reports and case series, hence the treatment modality chosen is dependent on physician/facility experience and the clinical factors in each case.…”

Outcome of a giant coronary artery mycotic pseudoaneurysm secondary to non-typhoidSalmonellamanaged without surgical intervention

“…Anastomotic pseudoaneurysm after a CABG procedure has been reported in less than 1% of cases 10 11. These rare events occur mostly in degenerating grafts years after the bypass procedure.…”