Revascularize first, resect second: off-pump excision of giant SVG pseudoaneurysm

BACKGROUND: Saphenous vein graft pseudoaneurysm is a rare late complication of coronary artery bypass grafting. Management is particularly challenging when the pseudoaneurysm-bearing graft remains an active source of myocardial perfusion. A 67-year-old man presented 33 years after coronary artery bypass grafting with progressive exertional dyspnea. Echocardiography demonstrated a large mass abutting the right atrium. Computed tomography angiography showed a 10 × 7 × 6 cm partially thrombosed pseudoaneurysm arising from the saphenous vein graft to the right posterior descending artery, with right atrial compression. Coronary angiography demonstrated pseudoaneurysm filling from the graft, chronic native right coronary artery occlusion, patent mammary grafts, and severe proximal graft stenosis. The heart team considered transcatheter exclusion unsuitable because of the distal entry site, calcific graft disease, and ongoing distal right coronary dependence. Redo off-pump saphenous vein grafting to the right posterior descending artery was performed before old-graft ligation. After transit-time flow measurement confirmed new-graft function, the pseudoaneurysm-bearing graft was ligated proximally and distally and excised en bloc. The patient was discharged on postoperative day 5. Three-month computed tomography angiography demonstrated a patent new graft without residual pseudoaneurysm. DISCUSSION: This case highlights that graft patency and myocardial dependence should be defined before exclusion of a saphenous vein graft pseudoaneurysm. In selected patients, revascularization before graft sacrifice can be performed off pump, avoiding cardiopulmonary bypass while preserving myocardial perfusion.