PMC4736683_01
Imaging findings before the procedure. A: Transthoracic echocardiography. White arrow-heads indicate the SVG aneurysm. Size of SVG aneurysm was enlarged within 6 months. B: Chest X-ray, lateral view. White arrow-heads indicate the mass-like shadow. C: Enhanced CT. Enhanced CT revealed a large aneurysm of the SVG (38 x 42 mm in diameter; 80-mm long) and graft patency. White arrows indicate the SVG aneurysm. D: Coronary angiogram of the left coronary artery at the left anterior oblique with caudal view. LAD was totally occluded from the orifice. E: Angiogram of the SVG. The white arrow indicates the leakage of contrast medium from the proximal portion of the SVG. RV, right ventricle; PA, pulmonary artery; SVG, saphenous vein graft; CT, computed tomography; LAD, left anterior descending artery.
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Transthoracic echocardiography demonstrated that the SVG aneurysm had been progressively enlarging at a rate of 5 mm within 6 months from July 2012 (Fig. 1A). Besides, chest X-ray showed a mass-like shadow on the left side of mediastinum (Fig. 1B). Enhanced computed tomography (CT) revealed a large aneurysm of the SVG (diameter of aneurysm was 38 x 42 mm and its length was 80 mm) (Fig. 1C). Coronary angiogram (CAG) demonstrated that the native left anterior descending artery (LAD) was totally occluded from the origin to its mid portion (Fig. 1D) and was perfused by the SVG (Fig. 1E). In addition, there was a large leakage of contrast medium from the proximal portion of the SVG (Fig. 1D).
Transcatheter embolization systems and its fluoroscopic image. A: Picture of trans-catheter embolization systems. A 5.2-Fr and 100-cm length angiocatheter was introduced into a 7-Fr JR4.0 shaped with 85-cm length guiding catheter via the unidirectional valve. Moreover, a microcatheter was introduced into the SVG through the 5.2-Fr angicatheter. During the coil-embolization, a balloon located at the tip of the angiocatheter was inflated. B: Fluoroscopic image. The white circle indicates the inflated balloon of the 5.2-Fr angiocatheter. During trans-catheter embolization, we inflated this balloon at the orifice of the SVG to shut off the blood flow from the aorta. JR, Judkins right; SVG, saphenous vein graft.
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Then, we engaged a 7-Fr Judkins Right 4.0 guiding catheter of short length (85 cm) (Camino, GOODMAN, Aichi, Japan) to the SVG and inserted a 5.2-Fr angiocatheter (Selecon MP catheter II, Terumo Clinical Supply, Gifu, Japan), which had a balloon of 9.0 mm in diameter at the tip of the catheter, to the SVG via the 7-Fr guiding catheter (Fig. 2A). During the procedure, we inflated the balloon at the orifice of the SVG to shut off the blood flow from the aorta and to avoid drift of coils and distal embolism of the native LAD (Fig. 2B).
Imaging findings after the catheter intervention. A: Chest X-ray, lateral view. Three months after the trans-catheter embolization. White arrows indicate the deployed coils. B: Enhanced CT. Three months after the trans-catheter embolization. Enhanced CT revealed that the SVG remained occluded and that the size of the SVG aneurysm had decreased (diameter was 30 x 32 mm). White arrows indicate the SVG aneurysm. C: CAG of the left coronary artery at the left anterior oblique with caudal view. Just after the percutaneous coronary intervention for chronic total occlusion of the LAD. CAG showed a well-expanded CTO lesion without disappearance of any branches. D: CAG of the left coronary artery at the left anterior oblique with caudal view. One year after the trans-catheter embolization. CAG revealed that the LAD maintained its patency. E: Angiogram of the SVG just after the TCE. The angiogram revealed that the SVG did not recanalize just after the TCE. F: Angiogram of the SVG 1 year after the TCE. The angiogram revealed that the SVG did not recanalize 1 year after the TCE. CT, computed tomography; SVG, saphenous vein graft; CAG, coronary angiogram; LAD, left anterior descending artery; TCE, trans-catheter embolization.
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Terumo, Tokyo, Japan) from the mid portion of the LAD to the orifice of the left main trunk and performed simultaneously kissing balloon technique between the LAD and the left circumflex artery (LCx). The final CAG showed a well-expanded CTO lesion without disappearance of any branches (Fig. 3C). Finally, we achieved complete occlusion of the SVG (Fig. 3E, Supporting Information Movie). Three months after the TCE, chest X-ray and CT demonstrated that the SVG had not recanalized and the size of the aneurysm had decreased (Fig. 3A and B). One year after the TCE, CAG revealed that the LAD maintained its patency (Fig. 3D) and the SVG had not recanalized (Fig. 3F).