Hemoptysis caused by saphenous vein graft aneurysm late after coronary artery bypass grafting

Abstract

Clinical Summary A 67-year-old man was admitted to our hospital with hemoptysis. He had a history of hyperlipidemia and CABG 17 years previously at the age of 49, with SVGs to the posterior descending and obtuse marginal arteries, and a left internal thoracic artery graft to the left anterior descending artery at another institute. From the previous surgical findings, the SVG was large, showing a diameter of 4.5 mm. Therefore, proximal anastomotic sites for the SVG on the ascending aorta were carefully selected to avoid a large atheromatous plaque that had been identified intraoperatively. On physical examination at this admission, the patient was hemodynamically stable although hemoptysis persisted. An electrocardiogram did not show any ischemic change, and cardiac enzymes were normal. A chest radiograph showed a right hilar mass and an additional density in the right upper lung. A computed tomographic scan demonstrated a 4.0 2.0–cm aneurysm with a mural thrombus abutting the right side of the ascending aorta and consolidations in the right upper lung adjacent to the aneurysm (Figure 1). Cardiac catheterization demonstrated a patent left internal thoracic artery graft. However, both SVGs to the posterior descending and obtuse marginal arteries had occluded. An aortogram demonstrated a saccular aneurysm originating from the right side of the ascending aorta (Figure 2). At surgery, cardiopulmonary bypass was established, and a cannula was inserted in the right axillary artery before a reentry median sternotomy. On exploration, the aneurysm was densely adherent to the right upper lobe of the lung. After cardioplegic arrest was obtained, the aneurysm was resected, and the mural thrombus was removed. The aneurysm had ruptured into the lung. The orifice of the aneurysm in the ascending aorta was 1.5 cm in diameter. Patch angioplasty of the ascending aorta was performed with the use of a polyester graft, and partial resection of the right upper lobe of the lung adherent to the aneurysm was performed concomitantly. Revascularization of the posterior descending artery was not performed because there were no ischemic symptoms and the right gastroepiploic artery was too small to be useful as a possible graft to the posterior descending artery. The patient was easily weaned from bypass and made an uneventful recovery, without hemoptysis. Thereafter, he was discharged home.