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Delayed Intervention in a Giant Saphenous Graft Aneurysm
Session:
Sessão Melhores Casos Clínicos
Speaker:
Mariana Passos
Congress:
CPC 2024
Topic:
P. Other
Theme:
37. Miscellanea
Subtheme:
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Session Type:
Prémios, Registos e Sessões Especiais
FP Number:
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Authors:
Mariana Passos; Carolina Mateus; Joana Lima Lopes; Filipa Gerardo; Inês Miranda; Mara Sarmento; Pedro Magno; José Loureiro; Joao Bicho Augusto
Abstract
<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif">A 73-year-old man with a history of triple coronary artery bypass grafting (CABG) at age 46 years (left internal mammary artery to left descending artery, saphenous vein graft (SVG) to obtuse marginal artery (OMA) and SVG to posterior descending artery), was incidentally diagnosed with an SVG aneurysm (SVGA) seventeen years later, following a chest x-ray (CXR) and later confirmed by a computed tomography coronary angiography (CTCA) scan. The SVGA was in fact a pseudo-aneurysm of the SVG-OMA bypass, had 66mm of maximal diameter and extensive thrombosis. </span></span><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">A conservative approach was decided given the SVG thrombosis and asymptomatic status of the patient. The reevaluation CTCAs performed 2 and 8 years later, showed an increase in SVGA size to 75 and 80mm, respectively; after discussion in heart team, given the small dimension increase of SVGA in the 6-year time frame, a watchful waiting approach was still maintained. Twenty-seven years after CABG (10 years after the incidental diagnosis) the patient was admitted to the hospital with sudden chest pain and dyspnea. On admission he was tachypneic and hypoxemic. On pulmonary auscultation vesicular murmur was abolished in the lower two-thirds of the left hemithorax. The CXR showed a homogeneous opacity in the left hemithorax, obscuring the aneurysmal mass. A transthoracic echocardiogram showed preserved left ventricular ejection fraction and no regional wall motion abnormalities. The CTCA revealed an increase in the SVGA size to 94mm, with apparent mechanical compression exerted over the surrounding structures - left pulmonary veins, left branch of the pulmonary artery and almost complete collapse of the ipsilateral lung. Pleural effusion was also noted, with aspects suggesting hemothorax, but no evidence of active bleeding. The current clinical scenario was attributed to the mechanical effect of the aneurysm, and a decision was made in heart team to repair and drain the SVGA. During surgery, it was noted that the heart was pushed anteriorly and to the right by the giant SVGA. It was opened and blood clots were </span></span><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif">aspirated with decompression of the mass. After opening the left pleura, the surgical field was flooded with hemothorax that was impossible to contain, with rapid progression to refractory hypovolemic shock and death. No bleeding coming from the aneurysmal sac was noted during surgery.</span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif">SVGAs are a rare complication of CABG. Presently, there is a lack of consensus regarding its management. In this case, CABG was performed 27 years before, with 10 years of watchful waiting that were otherwise uneventful. Nevertheless, considering the SVGA substantial size, rapid growth, and classification as a pseudo-aneurysm, earlier referral for surgery could have allowed for repair before the onset of symptoms and lower surgical risk.</span></span></p>
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