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Infrainguinal saphenous vein graft aneurysm and aortic aneurysm
Eur J Vasc Endovasc Surg 12, 380-382 (1996)
CASE REPORT Infrainguinal Saphenous Vein Graft Aneurysm and Aortic Aneurysm A. Casha, R.J. Holdsworth, P.A. Stonebridge and P.T. McCollum
Department of Vascular Surgery, Ninewells Hospital and Medical School, Dundee, U.K.
Introduction
saphenous vein graft aneurysms which were associated with abdominal aortic aneurysms.
Saphenous vein is the preferred conduit for lower limb bypass surgery. Subsequent aneurysm formation within femoropopliteal grafts is regarded as an unusual complication. We report two cases of lower limb Please address all correspondence to: Mr R.J. Holdsworth, Department of Surgery, Ninewells Hospital and Medical School, Dundee DD1 9SY, U.K.
Case Reports
Case 1 A 59-year-old caucasian male had a reverse saphenous
Fig. 1. Operative photograph of aneurysm in Case 1.
1078-5884/96/070380 + 03 $12.00/0 © 1996 W. B. Saunders Company Ltd.
Vein Graft Aneurysm
vein, above-knee femoropopliteal graft in 1984. He had no evidence of hyperlipidaemia, hypertension or diabetes. In 1990 he underwent repair of an asymptomatic, 6.8 cm, inflammatory, abdominal aortic aneurysm. Nine years after his original operation he presented in October 1993, with a rapidly expanding, 6cm, saphenous vein graft aneurysm. The aneurysm was resected and a 9mm PTFE interposition graft interserted (Fig. 1). Macroscopically there was mild atherosclerotic degeneration in the vein graft.
Case 2
A 60-year-old caucasian male had a right in situ below knee, saphenous vein femoropopliteal bypass in 1983. Eleven years later in July 1994 he was admitted with a 5cm aneurysm of the femoropopliteal graft (Fig 2). Pre-operative angiography showed an infrarenal aortic aneurysm which measured 5.7cm on ultrasound.
381
The femoropopliteal graft was explored and the aneurysm excised and the defect bridged with a spiral panelled saphenous vein interposition graft.
Discussion
Aneurysmal dilatation of saphenous vein femoropopliteal bypass grafts is rare with only 15 other case reports in the literature. Szilagy et al. 1 described "aneurysmal dilatation" in 10 of 260 (3.8%) grafts followed-up with arteriography. Two other large series of 295 grafts and 298 grafts did not report aneurysms 2'3 although Denton et al. 4 did report two graft aneurysms in a series of 276 grafts one of which was in a cephalic vein. It would seem reasonable to conclude that the overall incidence of vein graft aneurysms is well under 1%. Szflagyi et al. 1 attributed aneurysmal dilation of vein grafts to atherosclerotic degeneration, however, it has been described without atherosclerosis.S'6 On reviewing the case reports a number of trends emerge in respect to the development of vein graft aneurysms. They can be classified into two types either diffuse dilation of the graft or a localised aneurysm formation. The majority have been reported in those who have had grafts undertaken at a relatively young age and there is usually a lag phase of many years before the aneurysms present. There appears to be an association with hyperlipidaemia in five cases and all these patients had diffuse aneurysmal dilatation of the grafts. 5-7 Five of the case reports have been associated with aortic aneurysms and two with popliteal aneurysms. 7-9 Saphenous vein aneurysms are also described in 5-8% of aortorenal grafts, 1°'11 coronary artery bypass grafts 12 and aortoenteric grafts. ~1 Renal artery graft aneurysms and dilatation are usually non-atheromatous and many grafts have been carried out for fibromuscular dysplasia. In view of the association of vein graft aneurysms with other arterial aneurysms we would recommend that any patient who presents with true aneurysmal dilation of a vein graft should be screened for an abdominal aortic aneurysm.
References
Fig. 2. Arteriogram from Case 2 showing a large aneurysm.
1 SZILAGYIDE, ELLIOTTJE HAGEMANJH, SMITHRF, DALL~OLMoCA. Viological fate of autogenous vein implants as arterial substitutes: Clinical, angiographic and histopathologic observations in femoropopliteal operations for atherosclerosis. Ann Surg 1973; 178: 232-246. Eur J Vasc Endovasc Surg Vol 12, October 1996
:382
A. Casha et aL
2 DARLINGRC, LINTON RR, RAZZUKMA. Saphenous vein bypass grafts for femoropopliteal occlusive disease. Surgery 1967; 61: 31-40. 3 CUTLER et al. Autologous saphenous vein femoropopliteal bypass: analysis of 298 cases. Surgery 1976; 79: 325-331. 4 DENTONMJ, McCowAN MA, SCOTTDE True aneurysm formation in femoropopliteal autogenous vein bypass grafts: two cases. Aust NZ J Surg 1983; 53: 317-320. 5 BEYERSRFM, RIJKBENJFWB. Femoral occlusion in a young racing cyclist and nonatherosclerotic aneurysms in the autogenous saphenous vein graft used - - A case report. Vascular Surgery 1988; 269-274. 6 KELLY PH, JULSRUDJM, DYRUD PE, BLAKE DP. Aneurysmal rupture of a femoropopliteal saphenous vein graft. Surgery 1990; 107: 468-470. 7 PEER RIVI, UPSON JE Aneurysmal dilatation in saphenous vein bypass grafts. J Cardiovasc Surg 1990; 31: 668~71. 8 DE LA ROCHA AG, PEIXOTORS, BAn~D RJ. Atherosclerosis and
Eur J Vasc Endovasc Surg Vol 12, October 1996
9 10 11 12
aneurysm formation in a saphenous vein-graft. Br J Surg 1973; 60: 72-73. FRIEDMANSA, CERRUTI1VIM, GERSTMANNKE, WASHORH. Aneurysm formation: A late complication of venous by-pass grafting. Am Heart J 1975; 89: 366-368. STANLEYJC, ERNST CB, FRY WJ. Fate of 100 aortorenal grafts: characteristics of late graft expansion, aneurysmal dilatation and stenosis. Surgery 1973; 74: 931-944. DEAN RH, WILSON JP, BURKO H, FOSTERJH. Saphenous vein aortorenal bypass grafts: serial angiographic study. Ann Surg 1974; 180: 469-477. TEJA KT, DILLINGHAMR1 MENTZERRtVI. Saphenous vein aneurysms after aortocoronary bypass grafting: postoperative interval and hyperlipidaemia as determining, factors. Am Heart Journal 1987; 113: 1527-1529.
Accepted 9 May 1995
CASE REPORT Infrainguinal Saphenous Vein Graft Aneurysm and Aortic Aneurysm A. Casha, R.J. Holdsworth, P.A. Stonebridge and P.T. McCollum
Department of Vascular Surgery, Ninewells Hospital and Medical School, Dundee, U.K.
Introduction
saphenous vein graft aneurysms which were associated with abdominal aortic aneurysms.
Saphenous vein is the preferred conduit for lower limb bypass surgery. Subsequent aneurysm formation within femoropopliteal grafts is regarded as an unusual complication. We report two cases of lower limb Please address all correspondence to: Mr R.J. Holdsworth, Department of Surgery, Ninewells Hospital and Medical School, Dundee DD1 9SY, U.K.
Case Reports
Case 1 A 59-year-old caucasian male had a reverse saphenous
Fig. 1. Operative photograph of aneurysm in Case 1.
1078-5884/96/070380 + 03 $12.00/0 © 1996 W. B. Saunders Company Ltd.
Vein Graft Aneurysm
vein, above-knee femoropopliteal graft in 1984. He had no evidence of hyperlipidaemia, hypertension or diabetes. In 1990 he underwent repair of an asymptomatic, 6.8 cm, inflammatory, abdominal aortic aneurysm. Nine years after his original operation he presented in October 1993, with a rapidly expanding, 6cm, saphenous vein graft aneurysm. The aneurysm was resected and a 9mm PTFE interposition graft interserted (Fig. 1). Macroscopically there was mild atherosclerotic degeneration in the vein graft.
Case 2
A 60-year-old caucasian male had a right in situ below knee, saphenous vein femoropopliteal bypass in 1983. Eleven years later in July 1994 he was admitted with a 5cm aneurysm of the femoropopliteal graft (Fig 2). Pre-operative angiography showed an infrarenal aortic aneurysm which measured 5.7cm on ultrasound.
381
The femoropopliteal graft was explored and the aneurysm excised and the defect bridged with a spiral panelled saphenous vein interposition graft.
Discussion
Aneurysmal dilatation of saphenous vein femoropopliteal bypass grafts is rare with only 15 other case reports in the literature. Szilagy et al. 1 described "aneurysmal dilatation" in 10 of 260 (3.8%) grafts followed-up with arteriography. Two other large series of 295 grafts and 298 grafts did not report aneurysms 2'3 although Denton et al. 4 did report two graft aneurysms in a series of 276 grafts one of which was in a cephalic vein. It would seem reasonable to conclude that the overall incidence of vein graft aneurysms is well under 1%. Szflagyi et al. 1 attributed aneurysmal dilation of vein grafts to atherosclerotic degeneration, however, it has been described without atherosclerosis.S'6 On reviewing the case reports a number of trends emerge in respect to the development of vein graft aneurysms. They can be classified into two types either diffuse dilation of the graft or a localised aneurysm formation. The majority have been reported in those who have had grafts undertaken at a relatively young age and there is usually a lag phase of many years before the aneurysms present. There appears to be an association with hyperlipidaemia in five cases and all these patients had diffuse aneurysmal dilatation of the grafts. 5-7 Five of the case reports have been associated with aortic aneurysms and two with popliteal aneurysms. 7-9 Saphenous vein aneurysms are also described in 5-8% of aortorenal grafts, 1°'11 coronary artery bypass grafts 12 and aortoenteric grafts. ~1 Renal artery graft aneurysms and dilatation are usually non-atheromatous and many grafts have been carried out for fibromuscular dysplasia. In view of the association of vein graft aneurysms with other arterial aneurysms we would recommend that any patient who presents with true aneurysmal dilation of a vein graft should be screened for an abdominal aortic aneurysm.
References
Fig. 2. Arteriogram from Case 2 showing a large aneurysm.
1 SZILAGYIDE, ELLIOTTJE HAGEMANJH, SMITHRF, DALL~OLMoCA. Viological fate of autogenous vein implants as arterial substitutes: Clinical, angiographic and histopathologic observations in femoropopliteal operations for atherosclerosis. Ann Surg 1973; 178: 232-246. Eur J Vasc Endovasc Surg Vol 12, October 1996
:382
A. Casha et aL
2 DARLINGRC, LINTON RR, RAZZUKMA. Saphenous vein bypass grafts for femoropopliteal occlusive disease. Surgery 1967; 61: 31-40. 3 CUTLER et al. Autologous saphenous vein femoropopliteal bypass: analysis of 298 cases. Surgery 1976; 79: 325-331. 4 DENTONMJ, McCowAN MA, SCOTTDE True aneurysm formation in femoropopliteal autogenous vein bypass grafts: two cases. Aust NZ J Surg 1983; 53: 317-320. 5 BEYERSRFM, RIJKBENJFWB. Femoral occlusion in a young racing cyclist and nonatherosclerotic aneurysms in the autogenous saphenous vein graft used - - A case report. Vascular Surgery 1988; 269-274. 6 KELLY PH, JULSRUDJM, DYRUD PE, BLAKE DP. Aneurysmal rupture of a femoropopliteal saphenous vein graft. Surgery 1990; 107: 468-470. 7 PEER RIVI, UPSON JE Aneurysmal dilatation in saphenous vein bypass grafts. J Cardiovasc Surg 1990; 31: 668~71. 8 DE LA ROCHA AG, PEIXOTORS, BAn~D RJ. Atherosclerosis and
Eur J Vasc Endovasc Surg Vol 12, October 1996
9 10 11 12
aneurysm formation in a saphenous vein-graft. Br J Surg 1973; 60: 72-73. FRIEDMANSA, CERRUTI1VIM, GERSTMANNKE, WASHORH. Aneurysm formation: A late complication of venous by-pass grafting. Am Heart J 1975; 89: 366-368. STANLEYJC, ERNST CB, FRY WJ. Fate of 100 aortorenal grafts: characteristics of late graft expansion, aneurysmal dilatation and stenosis. Surgery 1973; 74: 931-944. DEAN RH, WILSON JP, BURKO H, FOSTERJH. Saphenous vein aortorenal bypass grafts: serial angiographic study. Ann Surg 1974; 180: 469-477. TEJA KT, DILLINGHAMR1 MENTZERRtVI. Saphenous vein aneurysms after aortocoronary bypass grafting: postoperative interval and hyperlipidaemia as determining, factors. Am Heart Journal 1987; 113: 1527-1529.
Accepted 9 May 1995