Aneurysm of a saphenous vein bypass graft associated with aneurysms of native coronary arteries

Aneurysm formation in saphenous vein aortocoronary bypass grafts is an extremely rare complication of coronary artery bypass surgery. Aneurysms of native coronary arteries are found in a small percentage of patients at autopsy. Reported is a case with multiple coronary artery aneurysms in which a dissecting aneurysm of the saphenous vein bypass graft also developed following coronary artery bypass surgery. This is the first report of such association.     

Brachial approach directional coronary atherectomy of a left coronary artery saphenous vein bypass graft

Directional coronary atherectomy (DCA) of a saphenous vein bypass graft to the left coronary artery was performed percutaneously from the brachial artery approach using a 7F endomyocardial biopsy sheath. Initial positioning was accomplished with a left bypass graft catheter inserted in the sheath. This technique permits use of smaller catheters than usual for DCA in patients in whom larger guides cannot be used. © 1993 Wiiey-Liss, Inc.     

Sudden occlusion of a saphenous vein bypass graft relieved by direct injection of nitroglycerine

An unusual case of sudden occlusion of a saphenous vein bypass graft to the right coronary artery, during a coronary angtographlc study, is presented. Such occlusion was relieved by direct intragraft nitroglycerine injection, as typically happens in case of coronary arterial spasm. A possible pathogenetlc mechanism, based on the present knowledge of platelet aggregation and the role of the powerful vasoactive agent Throm-boxane A₂, is discussed.     

Competitive blood flow in the coronary circulation simulating progression of proximal coronary artery disease after saphenous vein bypass surgery

We report a case of competitive blood flow in the left coronary circulation after saphenous vein bypass grafting that resulted in the apparent progression of a proximal stenosis to total occlusion at coronary angiography. Repeat angiography with careful attention to catheter position and adequate injection of contrast agent demonstrated the actual anatomy and showed that there was no postoperative change in the native coronary circulation. The true incidence of progression of proximal coronary disease after saphenous vein bypass surgery is unknown, and reported figures may be falsely elevated because of unrecognized competitive flow patterns simulating obstruction.     

Heparin-induced thrombocytopenia presenting with thrombosis of multiple saphenous vein grafts and myocardial infarction

We report herein a patient with coronary artery disease that developed heparin-induced thrombocytopenia after coronary artery bypass graft with resulting thrombosis of multiple saphenous vein grafts and myocardial infarction after heparin exposure. The patient required lepirudin and a cardiac catheterization with placement of stents.     

Coronary artery spasm occurring late after vein graft surgery

A patient with classic effort angina and high-grade, fixed proximal coronary atherosclerosis underwent a single saphenous vein graft to a large, dominant right coronary artery (RCA). After being asymptomatic for 1 ¹/₂ years, she had several episodes of rest angina culminating In Prinzmetal angina and ventricular fibrillation. Electrocardiographic changes occurred in the RCA distribution. Symptoms subsided with oral nifedlpine therapy. Angiography revealed intact vein graft and coronary circulation. The patient has done well for a follow-up period of 7 months.     

Paracardiac masses caused by a right coronary artery aneurysm and a saphenous vein graft aneurysm

Two unusual cases of large aneurysms, one located in the native right coronary artery and the other in a saphenous vein graft, are reported. Their size and mode of presentation as asymptomatic paracardiac masses on chest x-ray films make them unique. It is proposed that these entities be considered as part of the differential diagnosis of paracardiac masses.     

Ruptured saphenous venous graft pseudoaneurysm presenting as a pulsatile chest mass

A 72‐year‐old man with prior history of coronary artery bypass grafting and sternal wire infection presented with non‐ST‐segment elevation myocardial infarction. His coronary angiogram revealed stenosis of the distal left main coronary artery (LMCA) and a pseudoaneurysm of saphenous venous graft (SVG) to right posterior descending artery. Patient developed ventricular fibrillation during admission, and postcardiopulmonary resuscitation, a pulsatile chest mass was observed which was diagnosed with computed tomography as a chest wall collection resulting from rupture of the pseudo‐aneurysm. He underwent percutaneous coronary intervention of the LMCA with drug‐eluting stents followed by successful coil embolization of the SVG pseudoaneurysm. Patient had an uneventful recovery postprocedure.     

Timing of coronary artery bypass graft surgery following acute myocardial infarction: a critical literature review

Despite more than 30 years' experience with coronary artery bypass surgery, controversy still exists about the optimal timing of surgical revascularization following acute myocardial infarction. To review the published information on this topic, a Medline search of the literature published between 1984 and October 2000 was performed. After reviews and individual case reports we re excluded, 11 retrospective and prospective studies remained for analysis. Pervasive heterogeneity with respect to inclusion criteria, outcome measurement, definitions, variance among studies of measured time between myocardial infarction (MI) and coronary artery bypass graft (CABG), differences in study endpoints, and evolution of surgical techniques and medical regimens over this time precluded formal meta-analysis. Although prospective randomized trials are lacking, the preponderance of data from the 11 retrospective and prospective observational studies suggests that timing of bypass surgery after infarction is not an independent predictor of outcome and that delaying coronary bypass surgery for an arbitrary period of time following acute MI is unwarranted. Rather, ventricular function, post-infarction ischemia, noncardiac comorbid conditions, and the urgency of the surgery itself constitute the important predictors of perioperative mortality, and these clinical factors should be used to estimate perioperative risk and decide upon the risk:benefit relationship for CABG in this patient population.     

Poor long‐term patient and graft survival after primary percutaneous coronary intervention for acute myocardial infarction due to saphenous vein graft occlusion

Primary percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) due to saphenous vein graft (SVG) occlusion has been associated with poor procedural results and poor short‐term outcomes, but long‐term graft patency and patient survival have not been evaluated. Consecutive patients (n = 2,240) with STEMI treated with primary PCI from 1984 to 2003 were followed for 6.6 years (median). Follow‐up angiography was obtained in 80% of hospital survivors following primary PCI for SVG occlusion at 2.3 years (median). Patients with primary PCI for SVG occlusion (n = 57) vs. native artery occlusion had more prior MI, advanced Killip class, and three‐vessel coronary disease and lower acute ejection fraction (EF). Patients with SVG occlusion had lower rates of TIMI 3 flow post‐PCI (80.7% vs. 93.6%; P = 0.0001), higher in‐hospital mortality (21.1% vs. 8.0%; P = 0.0004), and lower follow‐up EF (49.3% vs. 54.7%; P = 0.055). Culprit SVGs were patent in 64% of patients at 1 year and 56% at 5 years. Late survival was strikingly worse in patients with primary PCI for SVG occlusion vs. native vessel occlusion (49% vs. 76% at 10 years), and SVG occlusion was the second strongest predictor of late cardiac mortality by multivariate analysis (HR = 2.11; 95% CI = 1.38–3.23; P = 0.0006). Patients with STEMI due to SVG occlusion treated with primary PCI have poor acute procedural results, frequent late reocclusion, and very high late mortality. The introduction of new adjunctive therapies (distal protection, thrombectomy, and drug‐eluting stents) may improve short‐term outcomes, but improved long‐term outcomes may require new and more durable revascularization strategies. © 2005 Wiley‐Liss, Inc.     

Percutaneous coronary interventions on vein graft bifurcation lesions presenting as an acute coronary syndrome

Interventions on graft bifurcation lesions are uncommon, especially in the setting of acute coronary syndromes (ACS). We described three cases of graft bifurcation intervention where we tailored our approach based on lesion characteristics, anatomy, and angulation to achieve excellent angiographic and clinical outcomes. In case 1, shared ostia of saphenous vein graft (SVG) to Diagonal (D) and Radial graft to Obtuse Marginal (OM) was severely stenosed. We prioritized the radial arterial graft as it is known to have a longer patency rate over a totally occluded SVG of an undetermined period. We performed provisional stenting of the ostium of the radial artery and balloon angioplasty of the SVG ostium, while stenting the body of the SVG. In case 2 (bifurcation lesion at the anastomosis of SVG to D1 and sequential jump graft to OM), we utilized a V stenting strategy after an embolization protection device (EPD) was deployed in the branch with a suitable landing zone. Kissing balloon dilatation of both the branches was performed both pre- and poststenting. In case 3 (bifurcation lesion at SVG to OM and Sequential “T” graft to diagonal), there was >90% angulation between both the grafts. We used “T” stenting strategy in this case. At 2-year follow-up, patients had no major adverse cardiovascular events since and remained symptom free.     

Thrombolysis in an aortocoronary saphenous vein graft

Selective intracoronary infusion of streptokinase during the acute phase of myocar-dial infarction may reduce myocardial necrosis. Thrombolytic therapy of acute myocardial infarction has been primarily applied to the native coronary circulation. We are reporting successful thrombolysis in an aortocoronary saphenous vein graft 39 months after bypass surgery. Thrombosis may have developed as a complication of catheterization, and streptokinase may also prove useful in the reversal of thrombosis in this setting.     

Giant saphenous vein graft pseudoaneurysm to right posterior descending artery presenting with superior vena cava syndrome

Saphenous vein grafts (SVG) pseudoaneurysms, especially giant ones, are rare and occur as a late complication of coronary artery bypass grafting. This condition affects both genders and typically occurs within the sixth decade of life. The clinical presentation ranges from an asymptomatic incidental finding on imaging studies to new onset angina, dyspnea, myocardial infarction or symptoms related to compression of neighboring structures. An 82-year-old woman presented with acute onset back pain, dyspnea and was noted to have significantly engorged neck veins. In the emergency department, a chest computed tomographic angiogram with intravenous contrast revealed a ruptured giant bilobed SVG pseudoaneurysm to the right posterior descending artery (RPDA). This imaging modality also demonstrated compression of the superior vena cava (SVC) by the SVG pseudoaneurysm. Coronary angiogram with bypass study was performed to establish the patency of this graft. Endovascular coiling and embolization of the SVG to RPDA was initially considered but disfavored after the coronary angiogram revealed preserved flow from the graft to this arterial branch. After reviewing the angiogram films, a surgical strategy was favored over a percutaneous intervention with a Nitinol self-expanding stent since the latter would have not addressed the superior vena cava compression caused by the giant pseudoaneurysm. Intraoperative transesophageal echocardiogram demonstrated SVC compression by the giant pseudoaneurysm cranial lobe. Our patient underwent surgical ligation and excision of the giant pseudoaneurysm and the RPDA was regrafted successfully. In summary, saphenous vein grafts pseudoaneurysms can be life-threatening and its therapy should be guided based on the presence of mechanical complications, the patency of the affected vein graft and the involved myocardial territory viability.     

在冠状动脉移植术中他汀类药物应用于静脉移植后狭窄机制研究进展

相比于左侧乳内动脉及桡动脉,大隐静脉在冠状动脉移植后的长期通畅率较低。一系列的临床试验和观察研究表明他汀类药物在静脉移植通畅率治疗上有显著的益处。除了能降低血脂外,他汀类药物可以在移植静脉的血管壁上直接抑制甲羟戊酸途径发挥多效性,并且可以降低小GTP酶比如Rho和Rac的香叶酰化。他汀类药物能够改善内皮功能的同时减少血管炎性反应及氧化应激,并且抑制平滑肌细胞的增殖与迁移。为了能将这些机制安全地运用到临床实践中,更多的临床试验需要聚焦于他汀类药物对静脉移植通畅率的干预作用,文章将对上述问题做一综述。     

冠状动脉旁路移植术中桡动脉与大隐静脉用于右冠状动脉系统的通畅率比较-倾向评分匹配分析

摘要 目的 对比桡动脉（radial artery,RA）与大隐静脉（great saphenous vein,GSV）作为移植血管在冠状动脉旁路移植术（coronary artery bypass grafting,CABG）中用于右冠状动脉系统的通畅率。方法 回顾分析2012年1月至2020年1月在北京医院心血管外科行CABG后复查冠状动脉CT血管成像（computer tomography angiography,CTA）的患者资料,其中RA用于右冠状动脉系统有34例（RA组）,GSV用于右冠状动脉系统86例（GSV组）,比较两组患者的资料,并根据性别、年龄、危险因素、合并症、心功能、EuroSCOREⅡ等基本资料进行倾向评分匹配（Propensity Score Matching,PSM）后,RA组和GSV组各21例入组,分析两组患者围术期各项指标及移植血管通畅情况。结果 GSV组患者年龄显著高于RA组（64.8±9.1 vs 60.7±9.8,p=0.001）,EuroSCOREⅡ评分显著高于RA组（1.62±1.46 vs 0.99±0.53,p=0.001）。PSM后两组间基线资料无显著差异（p＞0.05）,术中情况及术后并发症发生率无显著差异,GSV组和RA组患者随访时间无显著差异（12.33±14.47月 vs 9.50±13.35月,p=0.513）,RA的通畅率显著高于GSV的通畅率（51.7% vs 95.2%,p=0.004）。结论 RA作为移植血管用于右冠状动脉系统的通畅率显著高于GSV。     

冠状动脉搭桥术后静脉桥狭窄和新生易损斑块形成机制的研究进展

冠状动脉搭桥术术后发生桥血管病变是一种常见的现象,血栓形成、内皮功能障碍、血管痉挛和氧化应激是导致病变的重要机制。相比于动脉桥,静脉桥更易于发生病变,这与静脉本身的解剖形态和功能特征有着很大的关系。急性血栓形成、血管内膜增生和易损斑块形成是静脉桥不同时期发生病变的重要机制。使用抗血小板和调脂药物等冠心病二级预防药物有助于提高桥血管的开通率。寻找桥血管病变的预测因子及相关基因通路有望从细胞及分子学水平为静脉桥疾病提供新的研究方向。本文拟对冠状动脉搭桥术后发生静脉桥狭窄和新生易损斑块病变形成机制的研究进展作一综述。     

Aortocoronary saphenous vein graft rupture during diagnostic angiography

Coronary saphenous vein graft (SVG) rupture during diagnostic angiography is a very rare but known complication of the procedure. It has typically been reported to occur at the site of pseudoaneurysms or secondary to an interventional procedure involving the graft. We present a case of SVG mid‐body rupture during diagnostic angiography that occurred without evidence of pseudoaneurysmal changes. © 2013 Wiley Periodicals, Inc.     

Percutaneous treatment of a massive saphenous vein graft aneurysm

Saphenous vein graft (SVG) aneurysms are a rare, frequently late presenting, potentially fatal complication of coronary artery bypass graft (CABG) surgery. They are often discovered incidentally during radiological tasks such as chest x‐ray or CT but can present clinically with symptoms such as worsening angina and breathlessness as well as complications such as rupture or myocardial infarction. Given the risks if left untreated, consideration should be given to treatment either through percutaneous routes or open surgery. However, because of a lack of strong evidence, there are no definitive guidelines on the treatment of SVG aneurysms. We describe a patient with an extensive cardiac surgical history who presented with angina and breathlessness and was found to have a large SVG aneurysm, subsequently successfully treated with percutaneous coronary intervention with covered stents.     

胸部放疗后继发性冠心病的外科治疗体会

目的总结两例胸部放疗后继发冠状动脉粥样硬化性心脏病（冠心病）患者采用不停跳冠状动脉旁路移植术的手术的经验和随访结果,探讨这类患者的临床表现和治疗策略。方法回顾性分析两例放疗后分别出现心绞痛和心肌梗死的患者的临床资料,一例为何杰金病患者,另一例为乳腺癌患者,分别在接受〉40Gy放疗后8年和12年出现冠心病．并被冠状动脉造影检查证实为左主干狭窄合并三支病变,采用不停跳冠状动脉旁路移植术治疗取得成功。结合国外资料对这类患者手术指征,发病机制和临床特点进行分析讨论。结果两例均使用左乳内动脉和前降支吻合,无住院死亡和并发症,随访中一例术后接受了后续放疗和化疗,一例术后38个月由于肿瘤复发多器官衰竭死亡。结论恶性肿瘤患者放疗后需要严密随访,不能忽视心脏事件的发生和继发冠状动脉疾病的可能。对合并有三支病变的放疗后继发冠心病患者不停跳冠状动脉旁路移植术是安全和首选的方法。