Contrast-Enhanced Echocardiographic Evaluation of a Giant Saphenous Vein Graft Aneurysm

A 61-year-old man presented with unstable angina 16 years after undergoing coronary artery bypass grafting with a left internal mammary artery graft to the left anterior descending coronary artery and a sequential saphenous vein graft (SVG) to the right coronary artery and an obtuse marginal branch. Transthoracic echocardiography (TTE) with a Philips iE33 machine and an S5 transducer revealed a 5.3 cm × 4.6 cm mass with a central echolucent area, surrounded by a peripheral zone of increased echodensity adjacent to, and partially compressing, the right atrium. Contrast echocardiography following an intravenous bolus injection of Definity revealed late appearance of contrast within the mass consistent with a giant SVG aneurysm. Coronary artery bypass graft angiography revealed a giant aneurysm in the SVG proximal to the RCA anastomosis; the distal limb of the graft to the obtuse marginal branch was occluded. Under intravascular ultrasound guidance, a 7-mm spider filter was placed in the distal graft; then, a 6 mm × 10 cm Viabahn self-expanding nitinol polyethylene terephthalate-covered stent was deployed in the SVG with good seal zones proximally and distally. A follow-up contrast-enhanced transthoracic echocardiogram 1 day postprocedure revealed partial thrombosis of the aneurysm cavity. Ultrasound contrast did not appear in the aneurysm following intravenous injection, consistent with complete exclusion from the systemic circulation. This is the first report demonstrating feasibility of contrast-enhanced transthoracic echocardiography for the diagnosis of SVG aneurysm and confirming procedural success by documenting exclusion from the systemic circulation following intervention.