A Complication of Vein Graft Aneurysm Following the Use of Cutting Balloon Angioplasty in Recurrent Infrainguinal Venous Conduit Stenosis
Article Outline
Abstract
Cutting balloon angioplasty (CBA) has been used in the revascularisation of coronary arteries; however, more recently a role has been suggested in the salvage of failing infrainguinal grafts. We report a case of a vein graft aneurysm following treatment of a vein graft stenoses using CBA. This is a rare complication of cutting balloon angioplasty which may become more prevalent as this technique becomes more widespread.
Keywords: Vein graft aneurysm, Cutting balloon angioplasty
Introduction
The use of autologous vein is the preferred conduit for lower extremity bypass procedures.1 Venous conduit grafts are however associated with stenosis as often noted in surveillance programmes.2
Current treatment options include open surgical revision, standard percutaneous transluminal balloon angioplasty (PTA) and cutting balloon angioplasty (CBA).
Cutting balloon angioplasty is an option in the treatment of recurrent vein graft stenosis. We report a rare but significant complication of vein graft aneurysm following cutting balloon angioplasty.
Case report
A 64 year old female patient presenting with critical limb ischemia and rest pain underwent an elective femoral popliteal above knee bypass using an in situ long saphenous vein (LSV).
Preoperatively, the ipsilateral LSV ranged from between 3.7
mm at the groin to 3.0mm at the knee.
She was discharged home with dual antiplatelet therapy of Aspirin 75mg o.d. and Clopidogrel 75mg o.d.
Duplex surveillance followed by angiography at three months post operatively identified a stricture close to the distal anastomosis with a PSV gradient of 3.
Her ABPI had dropped from 0.9/0.9 to 0.8/0.8.
A digital subtraction angiography (DSA) (Fig. 1) and transluminal balloon angioplasty (PTA) to 4mm was performed 5 months after her initial operation, with an immediate return to normal in her ABPI measurement.
Figure 1
Digital subtraction angiography revealing stenosis five months post femoral popliteal bypass.
Routine duplex scanning 6 weeks post PTA identified a recurrent (longer) stenosis with a PSV of 4 and reduced ABPI of 0.7/0.7. Digital Subtraction Angiography of the vein graft performed 7 months after her bypass surgery revealed the distal 15cm to be grossly abnormal and stenotic (Fig. 2a). PTA of the diseased segment with Cutting Balloon (Boston Scientific® 5mm×1cm 5atm) was carried out with reasonable end result (Fig. 2b). Her ABPI returned to 0.9/0.9.
Figure 2
(a) Digital subtraction angiography 7 months post femoral popliteal bypass revealing worsening of stenosis. This image was taken pre Cutting Ballon Angioplasty. (b) Digital subtraction angiography post CBA.
During the six month surveillance scan after her CBA, it was noted that although her ABPI remained at 0.9/0.9, a 2.6cm aneurysm had developed at the site of the cutting balloon angioplasty (Fig. 3).
Figure 3
Digital subtraction angiography 6 months post CBA revealing aneurysm.
This was repaired by excision of the aneurysm and a venous jump graft to the below knee popliteal artery using contralateral autogenous vein.
Discussion
Cutting balloon angioplasty (CBA) is more frequently being used in various situations where the results of standard balloon angioplasty have not been satisfactory.3
A recent study demonstrated a high degree of technical success with CBA used in infrainguinal lesions compared to results of balloon angioplasty in previous similar studies.4
The cutting balloon is a non-compliant, balloon catheter equipped with three-to-four microtome-sharp atherotomes. These atherotomes cause controlled linear fractures of the atherosclerotic plaque or myointimal lesion, thus theoretically reducing complications.3
However, a study looking at the short-term safety of CBA reported complication rates of up to 11%.5 These were all local complications and included graft ruptures, dissections and graft thrombosis. One case of graft aneurysm significantly smaller than the case we present was also reported.
The use of a 5mm CBA (smallest available in the department at that time) in this case may have provoked this complication. Studies propose that oversizing with cutting balloon correlates with a greater risk of complications and rupture than standard balloon.4, 5
Vein graft stenoses are commonly attributed to the development of intimal hyperplasia.2 Veins used as arterial bypass conduits experience increases in pressure and pulsatile hemodynamics, leading to increases in wall shear and radial stress and subsequent increase in collagen relative to other wall components (elastin, proteoglycans).
Trauma sustained to the intima and media layers during CBA may impact the ability of the vein to adapt to these forces. The progression to aneurysm degeneration may become inevitable secondary to inflammatory processes and their role in proteolytic degradation of the elastin and collagen fibers of the vessel wall.
The utility of aspirin and clopidogrel after surgical and endovascular infrainguinal revascularization remains undefined and warrants additional study. This patient's bypass was considered to be at high risk for occlusion. She was started on dual antiplatelet therapy as it was anticipated that the patient would be non-compliant with warfarin.
This case report highlights the rare yet significant potential for aneurysmal formation in venous grafts following CBA. Attention is also drawn to the importance of imaging graft surveillance after such procedures to ensure timely initiation of secondary interventions.
References
- . Infrainguinal vein graft stenosis: cutting balloon angioplasty as the first line treatment of choice. J Vasc Surg. 2008;47:960–966
- . Lower extremity vein graft failure: a translational approach. Vasc Med. 2008;13:63–74
- . Cutting balloons for the treatment of vascular stenoses. Eur Radiol. 2006;16:1675–1683
- . Infrainguinal cutting balloon angioplasty in de novo arterial lesions. J Vasc Surg. 2008;48(5):1182–1188
- . Cutting balloon angioplasty of autogenous infrainguinal bypasses: short-term safety and efficacy. J Vasc Surg. 2007;46(4):724–730
PII: S1533-3167(09)00014-4
doi:10.1016/j.ejvsextra.2009.04.001
© 2009 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- A complication of vein graft aneurysm following the use of cutting balloon angioplasty in recurrent infrainguinal venous conduit stenosis , 01 June 2009
