Case study: a SVG to RCA Type IV perforation
Complications - Coronary perforation
Consult this case study on a saphenous vein graft (SVG) to right coronary artery (RCA) Type IV perforation, female 80-year old patient referred for angiogram +/- PCI.
- Female, 86-year old referred for angiogram +/- PCI.
- Risk factors:
- Hypertension, hyperlipidemia, hypothyroidism and renal insufficiency
- CABG x 4 in 1998 (LIMA to LAD and 3 SVGs to diag 2, OM1 and RCA)
- Angina post-acute inferior STEMI
- ECG: normal sinus rhythm, RBBB (old) and inferior Q-waves
- Coronary angiogram revealed SVG to RCA as a culprit, LVEF = 35% with inferior hypokinesia
- 6Fr femoral sheath and JR4 guiding catheter
- 0.014” guidewire
- Distal protection device (3.5 - 5.5mm / 140cm)
Evidence of Type IV perforation with fistula leaking into LV.
Management of perforation
A bedside echo ruled out pericardial effusion but did not define the fistula.
Cardiac MR revealed a pseudoaneurysm arising from the right venous graft. It was compressing RV inflow at AV groove with a significant L-R shunt (1.5:1).
Covered stent positioning
Covered stent implanted
Final angiographic result
- Patient was asymptomatic
- Patient feeling well 5 months after procedure
- One case report of a SVG to OM was misplaced to left atrium, was treated successfully by coil
- Fistula closure with covered stents is a very viable and less invasive option than cardiac surgery for the treatment of this rare condition