Endoluminal Grafting for Percutaneous Aneurysm Exclusion in an Aortocoronary Saphenous Vein Graft: The First Clinical Experience

Abstract

Purpose: Aneurysms develop only rarely in aortocoronary saphenous vein grafts (SVGs), and the usual treatment is surgical replacement of the diseased segment. However, in patients at appreciable risk for redo surgery, alternative therapies are desirable. We report the first compassionate use of a percutaneously delivered endoluminal graft (ELG) for internal exclusion of an SVG aneurysm. Methods: A 47-year-old male with two coronary bypass procedures and SVG angioplasty presented with an 8-mm diameter aneurysm lying between 80% and 70% stenotic lesions in an SVG to the obtuse marginal branch. The risks of a third bypass operation were considerable, so the decision was made to attempt internal exclusion of the SVG aneurysm. Results: An ELG composed of 2.0-mm diameter unexpanded PTFE graft material with Palmaz stents for fixation was delivered with a low-profile system, but a second ELG was necessary for complete exclusion of the aneurysmal sac. Both ELGs were dilated after initial deployment. The patient was discharged after 9 days without sequelae, and he remains asymptomatic with arteriographically documented ELG patency 5 months after treatment. Conclusions: In this patient with limited therapeutic options, percutaneous aneurysm exclusion in an SVG was effective in restoring a viable blood conduit. It remains to be seen if ELGs have a potential in aortocoronary SVGs.

Fracture of coronary guidewire during rotational atherectomy with coronary perforation and tamponade

“…In the report by Ellis and colleagues [6], it is suggested that class-3 perforations with free extravasation of dye and early tamponade should all be managed operatively. Recently, the use of autologous saphenous vein grafts sewn to stents has been reported to be effective in sealing perforations [7,8], while we have reported the successful implantation of an endoluminal graft composed of expanded polytetrafluoroethylene sewn to a Palmaz stent in a similar application [9].…”

Coronary perforation: The solution is right on the table

“…With a glycoprotein inhibitor and TPA still on board as well as heparin, we were in a dilemma. Even though our institution was the site that first invented, developed, and reported the use of the PTFE covered coronary stent, at that time, no device was commercially available to the United States and the vessel was too small for our large handmade and homemade device [3]. As happens in many cath labs around the world, a quick thinking X-ray tech recommended that we might want to consider putting autologous blood in, something we had seen done in a patient who had liver biopsy where they continued to bleed after removing the biopsy material.…”

PCI on a tear: Not all perforations need coverage

“…In 1993, we successfully treated a complex aneurysmal lesion in a saphenous vein graft that was causing ischemic symptoms by creating a barrier to seal off the aneurysm by preparing the stent graft with commercially available PTFE, and a commercially available Palmaz stent. 2 We then subsequently treated six patients that had diffuse saphenous vein graft disease, aneurysms, and multiple restenoses. Our results and early work were presented in several international conferences, and we were grateful and overwhelmed with requests for use of our device for the treatment of coronary perforations, aneurysms, and saphenous vein disease.…”