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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Case of the Month
Case of the Month
Iatrogenic pseudoaneurysm following CABG : successful endovascular treatment
Iatrogenic pseudoaneurysm following CABG : successful endovascular treatment
Contributed by: Pavan Jadhav
Contributed by: Pavan Jadhav
Clinical profile:
Clinical profile:
A 50 year old man presented with th complaints of a gradually progressive swelling in upper chest since one month. He had undergone a CABG about one and half month back. The swelling was boggy and is present at the cephalad end nd in line with the midline scar of the CABG.
A 50 year old man presented with th complaints of a gradually progressive swelling in upper chest since one month. He had undergone a CABG about one and half month back. The swelling was boggy and is present at the cephalad end nd in line with the midline scar of the CABG.
Figure 1. Image of the patient shows the swelling over upper chest in line with the midline scar of the CABG.
Radiological findings:
Radiological findings:
Figure 2 (left). The axial image of the CT angiogram shows crowding of vessels and few air bronchogram suggestive atelectasis of medial and lateral segments of the right lower lung (left)
Fig 2 (centre) The coronal image shows a heterogenous density collection/SOL in the right perihilar region with a broad base towards the mediastinum and is present in continuous with the atelectasis of the right lower lung .
Figure 2 (right). The sagittal section shows a heterogenous density collection in the anterior chest wall , a pseudoaneurysm from the anterior walls of the ascending aorta.
Treatment:
Treatment:
The pseudoaneurysm was successfully closed with a Konar multifunctional occluder device.
The pseudoaneurysm was successfully closed with a Konar multifunctional occluder device.
Figure 3: Following the deployment of the Konar occulder, the pseudoaneurysm has been totally excluded from the circulation
Discussion:
Discussion:
A coronary artery bypass graft (CABG or CAG) is placed during a surgical procedure to increase blood flow to the myocardium due to coronary stenoses. Arteries or veins can be grafted during this procedure.
A coronary artery bypass graft (CABG or CAG) is placed during a surgical procedure to increase blood flow to the myocardium due to coronary stenoses. Arteries or veins can be grafted during this procedure.
Types of coronary artery bypass grafts
Types of coronary artery bypass grafts
1. Saphenous vein grafts: Saphenous vein grafts are the most widely used in coronary bypass surgeries. Saphenous vein conduits are harvested from legs and grafted from the ascending aorta (usually anterior aspect) to the coronary artery beyond the obstructive lesion. Saphenous grafts are most convenient, however most prone to occlusion.
1. Saphenous vein grafts: Saphenous vein grafts are the most widely used in coronary bypass surgeries. Saphenous vein conduits are harvested from legs and grafted from the ascending aorta (usually anterior aspect) to the coronary artery beyond the obstructive lesion. Saphenous grafts are most convenient, however most prone to occlusion.
2. Internal thoracic artery grafts: Left internal thoracic (or mammary) artery (ITA) grafts have emerged as the preferred bypass graft due to their excellent graft patency and close proximity to the left anterior descending artery (LAD). They are often referred to as LIMA grafts (left internal mammary artery grafts). The other arteries used s grafts are:
2. Internal thoracic artery grafts: Left internal thoracic (or mammary) artery (ITA) grafts have emerged as the preferred bypass graft due to their excellent graft patency and close proximity to the left anterior descending artery (LAD). They are often referred to as LIMA grafts (left internal mammary artery grafts). The other arteries used s grafts are:
3. Radial artery
3. Radial artery
4. Gastroepiploic artery
4. Gastroepiploic artery
Complications
Complications
1. Thrombosis: It is most common in the early postoperative period, due to improper anticoagulation or endothelial damage during surgery
1. Thrombosis: It is most common in the early postoperative period, due to improper anticoagulation or endothelial damage during surgery
2. Graft malposition or kinking
2. Graft malposition or kinking
• Graft kinking can cause graft occlusion.
• Graft kinking can cause graft occlusion.
• It is especially common in longer grafts and grafts with connector devices
• It is especially common in longer grafts and grafts with connector devices
3. Graft spasm
3. Graft spasm
• This is common in radial artery grafts. It is seen in the early postoperative period. In the case of graft spasm, the proximal graft appears narrower than distal graft.
• This is common in radial artery grafts. It is seen in the early postoperative period. In the case of graft spasm, the proximal graft appears narrower than distal graft.
4. Iatrogenic complications
4. Iatrogenic complications
• Graft damage during surgery
• Graft damage during surgery
• Retained clips
• Retained clips
5. Graft aneurysms
5. Graft aneurysms
• Aneurysmal dilatation of graft >2 cm is considered significant and will require surgery
• Aneurysmal dilatation of graft >2 cm is considered significant and will require surgery
• Pseudoaneurysms may arise at the proximal or distal ends of grafts. These are treated by surgery or endovascular techniques.
• Pseudoaneurysms may arise at the proximal or distal ends of grafts. These are treated by surgery or endovascular techniques.
Role MDCT (Coronary Angiography) in post CABG patients
Role MDCT (Coronary Angiography) in post CABG patients
For evaluation of graft patency post CABG, the gold standard investigation is percutaneous angiography which is invasive. The advantage of MDCT over percutaneous angiography for post CABG patients is it not only evaluate the graft patency in a non-invasive manner but also can evaluate for other complications such as Surgical site infections (SSIs) which encapsulates a spectrum of wound cmplications: superficial surgical wound infections (SSWI); ‘deep’ surgical wound infections (DSWI); mediastinitis; and wound dehiscence.
For evaluation of graft patency post CABG, the gold standard investigation is percutaneous angiography which is invasive. The advantage of MDCT over percutaneous angiography for post CABG patients is it not only evaluate the graft patency in a non-invasive manner but also can evaluate for other complications such as Surgical site infections (SSIs) which encapsulates a spectrum of wound cmplications: superficial surgical wound infections (SSWI); ‘deep’ surgical wound infections (DSWI); mediastinitis; and wound dehiscence.
A brief discussion on pseudo-aneurysms post CABG
A brief discussion on pseudo-aneurysms post CABG
Aortic root pseudo aneurysm is a rare complication and develops in less than 0.5% of cases after cardiac surgery (2) . Accurate preoperative diagnosis is critical in avoiding inadvertent rupture of the pseudo aneurysm during re-sternotomy (3.4) . Mediastinitis and graft infection are the most common risk factors for the formation of postoperative aortic root pseudoaneurysms (2, 5, 6).The most common location for postoperative pseudo aneurysms is the graft anastomosis site followed by the coronary artery anastomosis site, aortotomy site, aortic cannulation site and needle vent site. The risk of pseudo aneurysm rupture depends on location of pseudoaneurysm and its distance from the sternum. If the pseudoaneurysm is anterior and situated less than 2 cm from the sternum, the patients are considered at high risk for re-entry and cardiopulmonary bypass should be established before re-sternotomy (6,7). In order to minimize the risk of catastrophic haemorrhage from pseudo aneurysm rupture best approach for re-entry is the key consideration.
Aortic root pseudo aneurysm is a rare complication and develops in less than 0.5% of cases after cardiac surgery (2) . Accurate preoperative diagnosis is critical in avoiding inadvertent rupture of the pseudo aneurysm during re-sternotomy (3.4) . Mediastinitis and graft infection are the most common risk factors for the formation of postoperative aortic root pseudoaneurysms (2, 5, 6).The most common location for postoperative pseudo aneurysms is the graft anastomosis site followed by the coronary artery anastomosis site, aortotomy site, aortic cannulation site and needle vent site. The risk of pseudo aneurysm rupture depends on location of pseudoaneurysm and its distance from the sternum. If the pseudoaneurysm is anterior and situated less than 2 cm from the sternum, the patients are considered at high risk for re-entry and cardiopulmonary bypass should be established before re-sternotomy (6,7). In order to minimize the risk of catastrophic haemorrhage from pseudo aneurysm rupture best approach for re-entry is the key consideration.
The treatment of postoperative aortic root pseudo aneurysm remains primarily surgical. Aortic graft replacement is the treatment of choice, with patch repair usually reserved for small pseudo aneurysms (5,6,7) .
The treatment of postoperative aortic root pseudo aneurysm remains primarily surgical. Aortic graft replacement is the treatment of choice, with patch repair usually reserved for small pseudo aneurysms (5,6,7) .
There have been only a few case reports of successful endovascular treatment of postoperative aortic root pseudo aneurysms (8, 9) . There are limitations to such endovascular techniques depending on the location of the pseudo aneurysm and the size of the pseudo aneurysm neck. Stent-graft may not be an option in cases with an inadequate landing zone and in proximity to the great vessels (9) . Coil embolization has been reported to treat narrow-neck pseudo aneurysms. Thrombin injection has also been used 10 , but its utility may be limited with wide-neck pseudo aneurysms and proximity to the origin of the great vessels. In some cases, aortic root pseudo aneurysm may recur after operative repair (7, 11) . Surveillance CT is recommended to evaluate recurrence of pseudo aneurysms (6 ).
There have been only a few case reports of successful endovascular treatment of postoperative aortic root pseudo aneurysms (8, 9) . There are limitations to such endovascular techniques depending on the location of the pseudo aneurysm and the size of the pseudo aneurysm neck. Stent-graft may not be an option in cases with an inadequate landing zone and in proximity to the great vessels (9) . Coil embolization has been reported to treat narrow-neck pseudo aneurysms. Thrombin injection has also been used 10 , but its utility may be limited with wide-neck pseudo aneurysms and proximity to the origin of the great vessels. In some cases, aortic root pseudo aneurysm may recur after operative repair (7, 11) . Surveillance CT is recommended to evaluate recurrence of pseudo aneurysms (6 ).
Konar multifunctional occluder (MFO)device: It is a novel device which is primarily used for the closure of ventricular septal defects. Being multifunctional it has the potential to be useful in various structural cardiac defects.
Konar multifunctional occluder (MFO)device: It is a novel device which is primarily used for the closure of ventricular septal defects. Being multifunctional it has the potential to be useful in various structural cardiac defects.
References:
References:
• 1. Nieman K, Pattynama PM, Rensin BJ, et al. Evaluation of patients after coronary artery bypass surgery: CT angiographic assessment of grafts and coronary arteries. Radiology 2003; 229:749–756.
• 1. Nieman K, Pattynama PM, Rensin BJ, et al. Evaluation of patients after coronary artery bypass surgery: CT angiographic assessment of grafts and coronary arteries. Radiology 2003; 229:749–756.
• 2. Ropers D, Ulzheimer S, Wenkle E, et al. Investigation of aortocoronary artery bypass grafts by multislice spiral computed tomography with electrocardiographic-gated image reconstruction. Am J Cardiol 2001; 88:792–795.
• 2. Ropers D, Ulzheimer S, Wenkle E, et al. Investigation of aortocoronary artery bypass grafts by multislice spiral computed tomography with electrocardiographic-gated image reconstruction. Am J Cardiol 2001; 88:792–795.
• 3. Engelmann MG, Knez A, von Smekal A, et al. Noninvasive coronary bypass graft imaging after multivessel revascularization. Int J Cardiol 2000; 76:65–74.
• 3. Engelmann MG, Knez A, von Smekal A, et al. Noninvasive coronary bypass graft imaging after multivessel revascularization. Int J Cardiol 2000; 76:65–74.
• 4. Ha JW, Cho SY, Shim WH, et al. Noninvasive evaluation of coronary artery bypass graft patency using three-dimensional angiography electron beam CT. AJR Am J Roentgenol 1999; 172:1055–1059.
• 4. Ha JW, Cho SY, Shim WH, et al. Noninvasive evaluation of coronary artery bypass graft patency using three-dimensional angiography electron beam CT. AJR Am J Roentgenol 1999; 172:1055–1059.
• 5. Achenbach S, Moshage W, Ropers D, et al. Noninvasive, three-dimensional visualization of coronary artery bypass grafts by electron beam tomography. Am J Cardiol 1997; 79:856–861.
• 5. Achenbach S, Moshage W, Ropers D, et al. Noninvasive, three-dimensional visualization of coronary artery bypass grafts by electron beam tomography. Am J Cardiol 1997; 79:856–861.
• 6. Engelmann MG, von Smekal A, Knez A, et al. Accuracy of spiral computed tomography for identifying arterial and venous coronary graft patency. Am J Cardiol 1997; 80:569–574
• 6. Engelmann MG, von Smekal A, Knez A, et al. Accuracy of spiral computed tomography for identifying arterial and venous coronary graft patency. Am J Cardiol 1997; 80:569–574
• 7. Fitzgibbon GM, Kafka HP, Leach AJ, Keon WJ, Hooper GD, Burton JR. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5,065 grafts related to survival and reoperation in 1,388 patients during 25 years. J Am Coll Cardiol 1996; 28:616–626.
• 7. Fitzgibbon GM, Kafka HP, Leach AJ, Keon WJ, Hooper GD, Burton JR. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5,065 grafts related to survival and reoperation in 1,388 patients during 25 years. J Am Coll Cardiol 1996; 28:616–626.
• 8. Motwani JG, Topol EJ. Aortocoronary saphenous vein graft disease: pathogenesis, predisposition, and prevention. Circulation 1998; 97:916–931.
• 8. Motwani JG, Topol EJ. Aortocoronary saphenous vein graft disease: pathogenesis, predisposition, and prevention. Circulation 1998; 97:916–931.
• 9. Poston RS, Prastein D, Gu J, Lee A, Pierson R, Griffith B. Virchow’s triad, but not use of an aortic connector device, predicts vein graft thrombosis after offpump bypass. Heart Surg Forum 2004; 7:123–128.
• 9. Poston RS, Prastein D, Gu J, Lee A, Pierson R, Griffith B. Virchow’s triad, but not use of an aortic connector device, predicts vein graft thrombosis after offpump bypass. Heart Surg Forum 2004; 7:123–128.
• 10. Mukherji A, Chattopadhyay A, Ghosh S, Mohapatra SK, De A, Singhi AK. Novel use of Konar-multifunctional occluder. Cardiol Young. 2020 Nov;30(11):1722-1727.
• 10. Mukherji A, Chattopadhyay A, Ghosh S, Mohapatra SK, De A, Singhi AK. Novel use of Konar-multifunctional occluder. Cardiol Young. 2020 Nov;30(11):1722-1727.
. 11. Katsumata T, Moorjani N, Vaccari G, Westaby S. Mediastinal false aneurysm after thoracic aortic surgery. Ann Thorac Surg 2000; 70:547???552
. 11. Katsumata T, Moorjani N, Vaccari G, Westaby S. Mediastinal false aneurysm after thoracic aortic surgery. Ann Thorac Surg 2000; 70:547???552
. 12. Mukherji A, Chattopadhyay A, Ghosh S, Mohapatra SK, De A, Singhi AK. Novel use of Konar-multifunctional occluder. Cardiol Young. 2020 Nov;30(11):1722-1727.
. 12. Mukherji A, Chattopadhyay A, Ghosh S, Mohapatra SK, De A, Singhi AK. Novel use of Konar-multifunctional occluder. Cardiol Young. 2020 Nov;30(11):1722-1727.
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