1. Successful Percutaneous Management of a Giant Saphenous Vein Graft Aneursym
Edward Howard MBChB(Hons) PhD
Robert Lager MD
Augusto Pichard MD
Medstar Washington Hospital Center
Edward Howard MBChB(Hons) PhD
Robert Lager MD
Augusto Pichard MD
Medstar Washington Hospital Center

2. I/we have no real or apparent conflicts of interest to report.
Edward W. Howard, MD, PhD
I/we have no real or apparent conflicts of interest to report.

3. The Case
79-year-old male, with past history of four separate coronary artery bypass grafting procedures ( )
Presented with weight loss, hoarseness of the voice and vertigo.
Past history included hypertension, dyslipidemia, permanent atrial fibrillation, ischemic cardiomyopathy with EF of 35-40%, mitral regurgitation
No tobacco use, mild alcohol intake.
His exam showed a comfortable, thin but not cachectic patient with pulse of 55, blood pressure of 105/54, afebrile. No other pertinent physical exam findings.
Of note: recently diagnosed with vocal cord paralysis by his ENT

4. Radiology

5. CT
Likely SVG pseudoaneurysm versus true aneurysm with dimensions 7.3 x 6.6 x 8.7 cm
Severe native coronary artery disease
RIMA (supplying LAD) as well as the right ventricle with likely adhesions to the sternum
Hypokinesis of the anterior wall with preserved LV ejection fraction
Moderate to severe dilation of the right ventricle as well as the right and left atria.

6. 3D Reconstruction

8. The Procedure

9. The Procedure

11. 6 Month Outcome Returned for follow up with mildly improved symptoms
CT shows patent stent, progressive thrombosis of aneurysm, regression of pulmonary arterial compression

12. SVG Aneurysm First described by Riahi and colleagues in 19751
Rare, but multiple case reports and small case series and recent narrative meta-analysis2
Incidence of aortocoronary SVG is reportedly 0.07% (single institution with 5500 SVGs)3
Appears to be increasing in prevalence
Defined as >1.5x dilation of vessel diameter, but >10cm has been reported
68% of reported aneurysms occur >10 years after surgery
1. Riahi M, Mark Vasu C, Tomatis LA. J Thoracic Cardiovasc Surg. 1975;70:358 –359
2. F. Daniel Ramirez et al; Circulation, 2012;126:
3. Dieter RS et al. Cardiovasc Surg. 2003;11:507–513

13. Pathophysiology
Delayed presentation and low incidence suggest that arterial pressures alone are not the cause of late SVG aneursym. More likely:
Atherosclerotic changes
Orientation of smooth muscle fibers at the level of the valves
Dysfunction of graft endothelium
Separate group of early presentation SVG aneursyms
Infection
Unsuspected pre-existing disease in vein conduit
Factors in harvesting such as conduit injury
Surgical errors such as poor suture technique and reverse implantation

14. Outcomes of SVG Aneurysm
NOT BENIGN!
SVG Aneursym
Death
Myocardial Infarction
Rupture
Compression of Adjacent Structures

15. Outcome by Size Proportionate to size, but no size is safe!
Adapted from F. Daniel Ramirez et al; Circulation, 2012;126:

16. Percutaneous Management of SVG Aneurysm
Traditionally surgical
Coiling or closure devices have been used for SVGAs not supplying significant areas of viable myocardium
Covered aortic endograft has also been described as an endovascular option for SVGA occlusion.
To date, this is the largest SVGA to which this therapy has been successfully applied, suggesting it is an option for all sizes of SVGA

17. Questions?