Author + information
- Received August 14, 2012
- Revision received October 11, 2012
- Accepted October 26, 2012
- Published online April 1, 2013.
- Matthew J. Brooks, MBBS⁎,
- Leeanne Grigg, MBBS⁎,
- Peter Mitchell, MBBS†,
- Ravi Iyer, MBBS⁎,
- Dominica Zentner, MBBS⁎,
- Ai Vee Ng, MBBS⁎ and
- Ronen Gurvitch, MBBS⁎,⁎ ()
- ↵⁎Reprint requests and correspondence:
Mr. Ronen Gurvitch, Cardiology Department, the Royal Melbourne Hospital, Royal Parade Parkville, Melbourne, Australia 3050
A 67-year-old man with scleroderma was diagnosed with a giant (12.1 × 8.2 × 7.9 cm) saphenous vein graft (SVG) aneurysm while undergoing evaluation for dyspnea 15 years post-coronary artery bypass surgery. Computed tomography demonstrated the aneurysm to arise from the SVG supplying the second obtuse marginal just distal to its aortic anastomosis (Figs. 1 and 2).⇓⇓ These findings were confirmed during coronary angiography, and no distal communication with the left circumflex system was present. Closure was recommended, given the risk of rupture. A percutaneous approach was felt more appropriate than open repair, due to his comorbidities, the need for redo-sternotomy, and the proximity of the aneurysm to the posterior aspect of the sternum.
From a femoral arterial approach, the SVG was engaged with a 6-F LCB catheter (Cordis Corp., San Jose, California). The SVG proximal to the aneurysm was 5 mm in diameter and 6 mm in length (Fig. 3A). Aneurysm cavity access proved difficult primarily due to the superior takeoff of the graft. A 5-F Glidecath catheter was successfully introduced over an exchange length Terumo wire (Terumo Interventional Systems, Somerset, New Jersey), through which an exchange length J-wire could be successfully introduced with multiple wire loops created for greater support (Fig. 3B). A 5-F MPD guiding catheter (Cordis Corp.) was then successfully inserted into the aneurysm cavity (Fig. 3C), through which a 6 × 6 mm Amplatzer-vascular-plug II (AVP-II) (AGA Medical Corporation, Plymouth, Minnesota) was successfully deployed (Fig. 3D). Absence of flow and thrombosis of the aneurysm was confirmed on transesophageal echocardiogram (Fig. 4) and aortic angiography (Fig. 3E). At last follow-up, 6 months post-procedure, our patient remained well with no residual flow into the aneurysm cavity on repeat imaging.
Saphenous vein graft aneurysms are an uncommon complication of coronary artery bypass surgery with rupture conferring high mortality. A number of percutaneous treatment options can be employed, including atrial septal occluders, coils, and vascular plugs (1–4). We describe the novel use of an AVP-II (AGA) to overcome this difficult guide access, preventing septal occluder device use. With our technique, the AVP-II (AGA) post-deployment anatomically resembles a septal occluder device (Fig. 3D), with the advantage of being deliverable through a 5-F guiding catheter. The availability of this device in longer lengths also permits its use in this aforementioned manner in patients with longer proximal graft segments where concerns with regard to compression injury with a septal occluder device exist (maximum waist 4 mm). Oversizing of the device diameter by approximately 25% is required to eliminate embolization risk.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 14, 2012.
- Revision received October 11, 2012.
- Accepted October 26, 2012.
- American College of Cardiology Foundation
- Sura A.C.,
- Douglas J.S.
- Sonnenberg B.,
- Rutledge J.,
- Welsh R.