Abstract

Thrombosed venous bypass graft – pseudoaneurysm following coil embolization

posted by Pal Suranyi, M.D., PhD | Mar 13, 2008

Case history
This 67-year-old patient post CABG was admitted due to recurrent chest pain following microcoil embolization of his saphenous venous graft pseudoaneurysm performed at another institution.

Question
What is the cause of the persistent chest pain? Are any of the bypass grafts occluded/stenotic, or is the source of the pain extra-cardiac?

Diagnosis / Differential diagnosis
Acute graft thrombosis, myocardial infarction, myocardial ischemia due to graft stenosis, aortic dissection, pulmonary embolism, pericarditis, lung tumor

Findings
Thrombotic occlusion of previously stented venous graft (to the left circumflex artery) with large pseudoaneurysm without evidence of contrast enhancement and with numerous microcoils in place. Patent LIMA to the severely diseased mid LAD with good distal runoff.

Comment
In patients with persistent chest pain of unknown origin following CABG surgery, coronary CTA is an excellent tool for differential diagnosis. Acute graft occlusion can be quickly and efficiently diagnosed with Dual Source CT, while additional valuable information is also gained about the chest wall, lungs, other thoracic vessels and the native coronary arteries.

[1] 3D overview of the heart. The stented, occluded bypass graft that developed a pseudoaneurysm can be seen behind a LIMA which appears to be patent and feeding the LAD.	[2] Axial 5mm MIP of the proximal portion of the stented (two stents), occluded graft continuing into a thrombosed pseudoaneurysm. LIMA is also shown anterior to the stents.
[3] Axial MIP at the level of the severely diseased LAD. The coil used for embolizing the pseudoaneurysm can be seen in the center of this large, thrombosed mass.	[4] Distal MPR (0.75mm) of the heart reveals severe hypoattenuation of the myocardium posteriorly, corresponding to infarct in the region once supplied by the occluded graft.