Giant venous aneurysm jeopardising internal mammary arterial graft patency

Abstract

The authors report a 79-year old man with a history of coronary bypass surgery, presenting with acute heart failure and elevated troponin. Coronarography revealed a giant saphenous vein graft aneurysm, which was compressing the left internal mammary artery bypass graft. This was confirmed by a multislice enhanced-ECG gated cardiac CT, showing the venous aneurysm responsible for external compression of the arterial graft and its functional occlusion. Myocardial ischaemia, the mechanism leading to cardiac failure, was confirmed by hypoperfusion of the sub-endocardial area shown by the CT. The aneurysm was surgically removed without complications. The patient recovered and his cardiac function improved. This is the first recorded case of compression of the left internal mammary artery by an giant saphenous vein graft aneurysm having triggered severe myocardial ischaemia and heart failure. The authors review the incidence and complications of giant venous bypass graft aneurysms reported in the literature.

Figure 1:

Chest X-ray showing bilateral infiltrates compatible with lung oedema, cardiomegaly and an abnormal convexity of the left side of the heart, suggesting the aneurysm (black arrow).

Figure 2:

(A) Selective angiography of the SVG (lumen of the aneurysm). (B) Selective angiography of the LIMA showing an extrinsic compression by the venous graft aneurysm. (C) MS-CT view of the left ventricular wall showing sub-endocardial hypoperfusion (black arrows). (D & E) Two MS-CT views showing the venous graft aneurysm (red arrow) and its relationship with the LIMA graft (green arrow). (F) Surgical view of the LIMA (on the left side) and the opened venous graft aneurysm (on the right side).