A Unique Cause of Acute Bypass Graft Failure: Think Outside the Box

A 62-year-old male presented with non-ST elevation myocardial infarction. Cardiac catheterization revealed multivessel coronary artery disease. He underwent 3-vessel coronary bypass grafting (left internal mammary artery [LIMA]-left anterior descending [LAD], saphenous vein graft [SVG]-obtuse marginal [OM], and SVG-right posterior descending artery [RPDA])

On postoperative day (POD) 1, he developed complete heart block, biventricular failure (left ventricular ejection fraction [LVEF] 25%), and cardiogenic shock. Back in the operating room, he was found to have low flow in the SVG-RPDA. He was placed on central venoarterial extracorporeal membrane oxygenation (VA-ECMO) and brought to the cardiac catheterization lab with an open chest, two mediastinal drains, and bilateral chest tubes. An angiogram revealed patent LIMA-LAD and SVG-OM but occluded mid-SVG-RPDA (Video 1).

The SVG occlusion was treated with serial balloon inflations followed by mechanical and aspiration thrombectomy. Severe stenosis at distal graft anastomosis was revealed (Figure, A); however, this area was refractory to balloon inflations with immediate recoil (Video 2). Careful review of fluoroscopy revealed that a chest tube may be compressing the distal graft. The chest tube was removed and repeat angiography showed complete resolution of the stenosis (Figure, B, Video 2). The patient was treated with intravenous heparin and cangrelor for 48 hours.

On POD 3, VA-ECMO was decannulated and the patient’s chest was closed. He made a full recovery with LVEF improvement (60%) and was discharged home. A follow-up angiogram 17 months later revealed patent SVG-RPDA (Video 3). There are 5 prior reports of drain tube (mediastinal or pericardial) causing extrinsic SVG compression, all involving SVG-RPDA.^1-5 Our case highlights this rare etiology of acute graft failure (specifically SVG-RPDA) and emphasizes cognizance regarding all devices and tubes on fluoroscopy.

References

1.         Lan NSR, Edelman JJ, Erickson M. External compression of saphenous vein graft by surgical pericardial drain. J Cardiovasc Med (Hagerstown). 2022;23(12):819-820. doi: 10.2459/JCM.0000000000001379

2.         Raut MS, Verma A, Agarwal M, Maheshwari A. Graft compression by drain tube. Heart Views. 2016;17(4):140-141. doi: 10.4103/1995-705X.201778

3.         Svedjeholm R, Hakanson E. Postoperative myocardial ischemia caused by chest tube compression of vein graft. Ann Thorac Surg. 1997;64(6):1806-1808. doi: 10.1016/s0003-4975(97)01005-9

4.         Heestermans TM, Dambrink JH, Sie HT. Immediate myocardial infarction due to compression of a vein graft. Ann Thorac Surg. 2009;87(2):e15. doi: 10.1016/j.athoracsur.2008.11.024

5.         Damodaran S, Gourav KP, Aspari A, Kumar V, Negi P, Negi SL. A rare case report of early myocardial ischemia after coronary artery bypass surgery due to mechanical compression of vein graft by pericardial drainage tube: Role of transesophageal echocardiography. Ann Card Anaesth. 2020;23(1):100-102. doi: 10.4103/aca.ACA_233_18

Affiliations and Disclosures

From the ¹Department of Cardiovascular Disease, East Carolina University, Greenville, North Carolina, USA; ²Department of Cardiac Surgery, East Carolina University, Greenville, North Carolina, USA.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Neeraj Shah, MD, Department of Cardiovascular Disease, East Carolina University, 115 Heart Drive, Greenville, NC 27834, USA. Email: neerajshah86@gmail.com