Giant saphenous vein graft aneurysm

Case contributed by Dr Jayanth Keshavamurthy

Presentation

70 year old presents with chest pain and coronary artery disease presents prior to PCI please evaluate for pulmonary edema.

Patient Data

Age: 70
Gender: Male
Modality: X-ray


Patient has undergone previous sternotomy with wires. There are 2 SVG ring markers. Clips are seen along the LIMA and LAD. There is moderate to severe enlarged cardiopericardiac silhouette.

In the aortic pulmonary window there is a 6 x 9 cm density-masslike with clear smooth borders. This mass is displacing the LIMA surgical clips laterally, suggesting also this is a SVG aneurysm.

Findings consistent with hilum overlay sign-suggesting this lesion is either in the anterior or posterior mediastinum.

There is elevation of the left hemidiaphragm, suggesting there is left phrenic nerve palsy, either from this mass-like lesion or from prior surgery.

Also seen are multiple left rib fractures.

Emphysematous chest.

IMPRESSION:

Differential diagnosis for this mass like lesion,is likely in anterior or posterior mediastinum including aortic aneurysm or aneurysm within the saphenous venous graft. The saphenous venous grafts were completely occluded on cardiac catheterization.

Patient is elderly, had cardiac catheterization yesterday with more plans for cardiac catheterization, a noncontrast CT scan of the chest will be performed to start with.

Modality: CT

IMPRESSION:

  1. A very large SVG graft aneurysm. This SVG graft, likely involves the SVG going from the ascending aorta to obtuse marginal coronary artery. Given the calcifications and differential density, this is likely a thrombosed aneurysm.
  2. Ascending aorta is normal in dimension without ectasia or aneurysm.
  3. No pericardial effusion.
  4. Severe dense native coronary artery calcifications.
  5. Emphysema.
  6. Moderate to large left pleural effusion with compressive collapse of the left lower lobe.
Modality: DSA (angiography)

PROCEDURES PERFORMED


PTCA (Balloon Angioplasty Only)
IVUS
Rotational Atherectomy Single Vessel
Rotational Atherectomy Additional Vessel
Drug Eluting Stent Initial Vessel
IVUS Additional Vessel

CONCLUSIONS:
1. Successful PCI of LM & ostial ramus with rotational atherectomy and DES
2. PTCA of mid Ramus with acceptable results

FINDINGS:

Coronary Angiography:

  1. LEFT MAIN: heavily calcified, severe diffuse disease, 90 % stenosis
  2. RAMUS: heavily calcified, severe diffuse disease, 90 % stenosis

Case Discussion

The aneurysm in a non functional SVG was left alone. Only the native vessels were treated.

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Case Information

rID: 49393
Case created: 22nd Nov 2016
Last edited: 18th Dec 2016
Systems: Cardiac, Chest
Inclusion in quiz mode: Included

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