22: Saphenous Vein Graft Rupture

Published on 02/03/2015 by admin

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Last modified 02/03/2015

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CASE 22 Saphenous Vein Graft Rupture

Michael Ragosta, MD, FACC, FSCAI

Case presentation

While preparing for bed, an active and healthy 66-year-old man developed sudden-onset substernal chest pain radiating to his jaw. This pain reminded him of the angina he had experienced 14 years earlier, prior to coronary bypass surgery consisting of a left internal mammary artery graft to the left anterior descending artery, a right internal mammary artery graft to the right coronary artery, and a saphenous vein graft to a large second obtuse marginal artery. The pain lasted for 15 minutes and resolved with nitroglycerin. Evaluation in the hospital emergency department found no electrocardiographic abnormalities or rise in cardiac biomarkers. Following hospital admission and treatment with aspirin, unfractionated heparin, atenolol, and long-acting nitrates, his cardiologist performed a stress echocardiogram. During this test, he developed recurrent chest pain along with marked ST depression at a low workload with stress-induced lateral wall hypokinesis on echocardiography. Physical examination and routine laboratory studies were normal and he was referred for cardiac catheterization.

Cardiac catheterization

Angiography found wide patency of both internal mammary artery grafts and a severe proximal stenosis and moderately severe, more distal stenosis in the body of the 14-year-old vein graft to the obtuse marginal artery (Figures 22-1, 22-2 and Videos 22-1, 22-2). The operator planned to stent both the proximal and midgraft lesions with distal embolic protection afforded by the PercuSurge Guardwire (Medtronic) temporary balloon occlusion and aspiration system.¹ An 8 French, right Judkins guide catheter was inserted in the vein graft. The operator chose unfractionated heparin and eptifibatide for procedural anticoagulation, and the Guardwire was positioned distally in the vein graft. The occlusion balloon was inflated to allow distal embolic protection. After first dilating with a 3.5 mm diameter balloon, a 4.5 mm diameter by 18 mm long bare-metal stent was deployed in the proximal lesion (Figure 22-3). The operator then positioned and deployed a 4.0 mm diameter by 28 mm long bare-metal stent in the midgraft lesion. Aspiration was performed, the distal occlusion balloon deflated, and angiography performed. To the operator’s horror, free-flowing contrast was observed extravasating from a large defect in the midportion of the vein graft within the stented segment (Video 22-3). The patient developed marked hypotension with arterial pressure falling to 50/30 mmHg. To staunch the hemorrhage, a 3.5 mm perfusion balloon was positioned and inflated in the vein graft at the site of the defect, eptifibatide was discontinued, and 30 mg of protamine was administered intravenously. This greatly decreased the amount of contrast extravasation, and the perfusion balloon allowed distal perfusion; however, there remained evidence of ongoing hemorrhage by angiography (Video 22-4). Fluid resuscitation and dopamine infusion restored blood pressure, but each time the balloon was deflated for even a few seconds, the patient developed marked hypotension. Since the operator did not feel there was sufficient time to safely exchange the perfusion balloon for a PTFE-covered stent nor felt confident that the large defect could be successfully sealed with this device, cardiothoracic surgery agreed to operate on the patient emergently.