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Saphenous Vein Graft Aneurysms Treatment & Management

  • Author: Jesse P Jorgensen, MD; Chief Editor: Eric H Yang, MD  more...
 
Updated: Nov 10, 2014
 

Medical Care

The optimal approach to treating patients with saphenous vein graft aneurysms (SVGAs) is not well defined, with limited data consisting of case reports and case series. Treatment options include medical therapy with surveillance, surgical therapy, and percutaneous intervention. In the largest treatment series of SVGA, Dieter and colleagues report the outcome of 13 patients, of which 2 had surgical therapy and the remainder were deemed poor surgical candidates due to comorbid conditions. Eight patients had an uneventful follow-up course while being managed medically, and no survival benefit was attributed to either surgical or conservative management.[7]

Patients may be treated conservatively because of comorbid conditions precluding surgery or because of patient preference.

Medical therapy has also been pursued based on imaging characteristics suggesting low risk for rupture, such as a thick aneurysm wall or absence of flow into the aneurysm because of thrombus, especially in asymptomatic patients. Additional features that may support conservative management include aneurysm diameter less than 1 cm and brisk flow through the graft. This strategy should include surveillance imaging with MRI, CT, or coronary angiography to monitor aneurysm growth over time.

Note the following:

  • Antihypertensive and cholesterol-lowering therapy, such as with an HMG-CoA reductase inhibitor (statin), may be beneficial in slowing aneurysm progression but limited data are available.
  • The benefit of anticoagulant therapy with warfarin (Coumadin) is not known.
  • The role of beta-blockers in preventing further SVGA dilatation, in contrast to their role in treating aortic aneurysms, has not been well studied. However, many of these patients, particularly those with angina, left ventricular systolic dysfunction, and/or a history of myocardial infarction, benefit from beta-blocker therapy.
  • Aspirin is generally recommended in most patients with SVGA based on the presence of underlying coronary artery disease.

Careful monitoring in the ICU is required during the initial postoperative period if surgical resection or percutaneous intervention is performed.

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Consultations

Cardiologists and cardiac surgeons are required for thorough patient evaluation.

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Diet and Activity

A heart-healthy diet should be followed to decrease risk factors for further cardiac disease. The influence of diet on subsequent aneurysm formation is unknown.

Early mobilization followed by gradual resumption of normal activity is important for successful postoperative recovery.

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Surgical Care

Surgical therapy is generally considered when an SVGA is discovered, given the morbidity and mortality associated with aneurysm rupture. The optimal timing of surgery is unknown; however, in cases of symptomatic aneurysms, suspected mycotic aneurysm, fistula formation, and/or confirmed false aneurysm, urgent surgical intervention is strongly recommended.

The traditional surgical approach has been ligation of the aneurysm-containing SVG and placement of a new bypass graft.[8] Additional approaches include resection of the abnormal portions of the diseased graft with new SVG segments sewn in end-to-end, ligation of the old graft without revascularization, and hematoma evacuation with repair of the SVG with a venous patch graft. The latter 2 approaches have been successfully performed off-pump.

Historically, percutaneous therapy has been reserved for patients who are poor surgical candidates. However, as percutaneous techniques evolve, these approaches are being considered as alternatives to surgical intervention. Consider the following:

  • The most commonly used percutaneous approach has been coil embolization of the aneurysm (see videos below). This technique carries the risk of occluding flow to the bypassed arterial system. Recently, "stent-assisted" coil embolization has been described, whereby a stent is placed in the parent vessel across the mouth of the aneurysm, providing a scaffold to prevent prolapse of coils into the parent vessel once deployed in the aneurysm.
  • Rezq et al reported success with peripheral covered tents as an alternative to surgery. [9] See the images below.
    Angiogram of a saphenous vein graft to the distal right coronary artery demonstrating a large aneurysm in the mid portion of the graft. Video courtesy of John S. Douglas, MD.
    Final angiogram demonstrating coils within the aneurysm, and almost complete cessation of flow from the parent vessel into the aneurysm. Video courtesy of John S. Douglas, MD.
  • Covered stents have been used to isolate the aneurysm from the graft lumen; the JOSTENT Coronary Stent Graft (Abbott Vascular, Redwood City, Calif), that consists of an ultra-thin layer of polytetrafluoroethylene (PTFE) sandwiched between 2 stainless steel stents, has been used successfully in several cases. However, the results have been mixed due to technical issues. In one case, the JOSTENT migrated into the aneurysm, requiring placement of a second overlapping bare metal stent for repositioning, finally achieving a good result. In a second case, the JOSTENT achieved an excellent immediate angiographic result with exclusion of a false aneurysm, but on routine 6-month angiogram, the false aneurysm recurred in the same location, possibly due to focal perforation of the PTFE layer. [10]
  • Placement of autologous vein graft-covered stents has been used successfully, and in one patient where a covered stent was not immediately available, 3 overlapping uncovered stents with prolonged balloon inflation successfully excluded a false aneurysm.
  • Brilakis et al compared restenosis rates after the placement of paclitaxel-eluting stent versus bare metal stent in saphenous vein graft lesions. They found that paclitaxel-eluting stents were associated with lower rates of target vessel failure and angiographic restenosis than bare metal stents. [11]
  • A newer approach that has been used is placement of the Amplatzer vascular plug (AGA Medical, Golden Valley, MN); in the single reported case, an 8-mm device was placed in the neck of a 9-cm true SVGA with an excellent result. [12]
  • For patients undergoing percutaneous coronary intervention (PCI) in saphenous vein grafts, drug-eluting stents may be the preferred method of treatment because they have a lower risk of target vessel revascularization compared with bare metal stents. No differences are recognized between drug-eluting stents and bare metal stents in terms of stent thrombosis when used in saphenous vein graft interventions. [13]
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Contributor Information and Disclosures
Author

Jesse P Jorgensen, MD Fellow, Department of Cardiology, Emory University School of Medicine

Jesse P Jorgensen, MD is a member of the following medical societies: American College of Cardiology, American Heart Association

Disclosure: Nothing to disclose.

Coauthor(s)

Tarek Helmy, MD, FACC, FSCAI Professor of Medicine, Division of Cardiology, Director of Cardiac Catheterization Laboratory, University of Cincinnati School of Medicine

Tarek Helmy, MD, FACC, FSCAI is a member of the following medical societies: American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Heart Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven J Compton, MD, FACC, FACP, FHRS Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Physicians, American Heart Association, American Medical Association, Heart Rhythm Society, Alaska State Medical Association, American College of Cardiology

Disclosure: Nothing to disclose.

Chief Editor

Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catherization Laboratory and Interventional Cardiology, Mayo Clinic Arizona

Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Additional Contributors

Craig T Basson, MD, PhD Translational Medicine Head – Cardiovascular, Translational Medicine Head - Diabetes and Metabolism, Novartis Institutes for BioMedical Research

Craig T Basson, MD, PhD is a member of the following medical societies: American College of Cardiology, American Heart Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author Christian Birkedal, MD, and J Thomas Williams, MD, to the development and writing of this article.

References
  1. Riahi M, Vasu CM, Tomatis LA, et al. Aneurysm of saphenous vein bypass graft to coronary artery. J Thorac Cardiovasc Surg. 1975 Aug. 70(2):358-9. [Medline].

  2. Elgharably H, Kursbaum A, Flamm SD, et al. Mediastinal mass presented 36 years after coronary bypass grafting: is vein graft pseudoaneurysm a differential diagnosis?. Eur J Cardiothorac Surg. 2014 Sep 25. [Medline].

  3. Sherry CS, Harms SE. MR imaging of pseudoaneurysms in aortocoronary bypass graft. J Comput Assist Tomogr. 1989 May-Jun. 13(3):426-9. [Medline].

  4. Khabeishvili G, Shaburishvili T, Wann S, et al. Saphenous vein graft pseudoaneurysm: diagnosis by transesophageal echocardiography and magnetic resonance imaging. J Am Soc Echocardiogr. 1995 May-Jun. 8(3):338-40. [Medline].

  5. Benari B, Erel J, Allen HN, et al. Aneurysm of saphenous vein bypass graft detected by first-pass radionuclide ventriculography. Am Heart J. 1997 Jan. 133(1):133-6. [Medline].

  6. Ennis BM, Zientek DM, Ruggie NT, et al. Characterization of a saphenous vein graft aneurysm by intravascular ultrasound and computerized three-dimensional reconstruction. Cathet Cardiovasc Diagn. 1993 Apr. 28(4):328-31. [Medline].

  7. Dieter RS, Patel AK, Yandow D, Pacanowski JP Jr, Bhattacharya A, Gimelli G, et al. Conservative vs. invasive treatment of aortocoronary saphenous vein graft aneurysms: Treatment algorithm based upon a large series. Cardiovasc Surg. 2003 Dec. 11(6):507-13. [Medline].

  8. Ishishita Y, Tanikawa R, Noda K, Kubota H, Izumi N, Katsuno M, et al. Universal Extracranial-Intracranial Graft Bypass for Large or Giant Internal Carotid Aneurysms: Techniques and Results in 38 Consecutive Patients. World Neurosurg. 2013 Feb 20. [Medline].

  9. Rezq A, Politi L, Sangiorgi G. Long-term outcome of percutaneous exclusion of huge saphenous vein graft aneurysms using peripheral covered-stents as alternative to surgical repair. J Invasive Cardiol. 2012 Dec. 24(12):689-91. [Medline].

  10. Bosmans JM, Claeys MJ, Dilling D, Vrints CJ. Unsuccessful long-term outcome after treatment of a vein graft false aneurysm with a polytetrafluoethylene-coated Jostent. Catheter Cardiovasc Interv. 2000 May. 50(1):105-8. [Medline].

  11. Brilakis ES, Lichtenwalter C, de Lemos JA, Roesle M, Obel O, Haagen D, et al. A randomized controlled trial of a paclitaxel-eluting stent versus a similar bare-metal stent in saphenous vein graft lesions the SOS (Stenting of Saphenous Vein Grafts) trial. J Am Coll Cardiol. 2009 Mar 17. 53(11):919-28. [Medline].

  12. Mylonas I, Sakata Y, Salinger MH, Feldman T. Successful closure of a giant true saphenous vein graft aneurysm using the Amplatzer vascular plug. Catheter Cardiovasc Interv. 2006 Apr. 67(4):611-6. [Medline].

  13. Mehilli J, Pache J, Abdel-Wahab M, et al. Drug-eluting versus bare-metal stents in saphenous vein graft lesions (ISAR-CABG): a randomised controlled superiority trial. Lancet. 2011 Sep 17. 378(9796):1071-8. [Medline].

 
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CT scan demonstrating a saphenous vein graft aneurysm.
Cardiac catheterization demonstrating a saphenous vein graft aneurysm.
Aortogram demonstrating a saphenous vein graft aneurysm.
This CT scan reveals a saphenous vein graft aneurysm.
Angiogram of a saphenous vein graft to the distal right coronary artery demonstrating a large aneurysm in the mid portion of the graft. Video courtesy of John S. Douglas, MD.
Final angiogram demonstrating coils within the aneurysm, and almost complete cessation of flow from the parent vessel into the aneurysm. Video courtesy of John S. Douglas, MD.
Another view demonstrating the saphenous vein graft aneurysm. Video courtesy of John S. Douglas, MD.
The first of many coils being deployed in the aneurysm. Video courtesy of John S. Douglas, MD.
 
 
 
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