DESCRIPTION OF CLINICAL PRESENTATION:

A 66-year-old female patient with a history of CABG in 2009 presented to the emergency department with chest pain.

Diagnostic Techniques and Their Most Important Findings:

She underwent an echocardiogram, which revealed a cardiac mass compressing the left main coronary artery. The patient then had a cardiac MRI that showed a neo-cavity with the presence of a mural thrombus near the aortic root and its ascending portion, measuring 75x55 mm, with signs of slight extrinsic compression of the left atrium and significant extrinsic compression of the pulmonary arteries and the left main coronary artery, consistent with a pseudoaneurysm of the venous graft from the aorta to the second marginal branch. The diagnosis was then confirmed by coronary artery CT angiography, and the patient was referred for percutaneous closure with a 12 x 09 mm Amplatzer device and angioplasty of the left main coronary artery, with successful results.

LEARNING POINTS FROM THIS CASE:

Pseudoaneurysms of SVG are rare complications of a CABG surgery 1. It’s defined by the disruption of at least one of the layers of the vessel wall resulting in a hematoma surrounding peri-vascular tissue; differing from the true aneurysm, which involves all 3 layers of the blood vessel and are more related to thrombus formation due to turbulent flow 4. The occurrence of pseudoaneurysms of SVG can occur in an early scenario, which are more related to anastomotic breakdown, infection or hypertension; and in a late postoperative period, such as the case report 5. In this late scenario, its described approximatively 15 years after CABG is performed; and the reason may be related to progressive atherosclerosis and intimal hyperplasia, which results in a loss of tissue elasticity 2,3. The clinical presentation can be very heterogeneous, but approximately one-half of the patient experienced chest pain, such as the patient in our case report 2. The reappearance of chest pain may be related to angina, myocardial infarction or pseudoaneurysm rupture. Despite the invasive coronary angiography (ICA) remains the gold standard procedure to characterize SVG, and the significant expansion of the use of computed tomography (CT) in this setting, in contrast, our diagnose was made through CMRA 5. It has been shown in previous case reports that gradient-echo and segmented k-space cine MRI techniques, as the ones applied in this case, are sensitive and specific for describing the SVG patency, unless the vascular clips along the graft limited this evaluation 5.