Saphenous Vein Graft Aneurysms Treatment & Management

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

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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