Surgeons Excise Giant Graft Pseudoaneurysm Off-Pump After Restoring Blood Flow

A 67-year-old man who had undergone coronary artery bypass grafting 33 years earlier developed a rare and dangerous late complication: a saphenous vein graft pseudoaneurysm measuring 10 × 7 × 6 centimeters. The partially thrombosed mass, arising from the vein graft that supplied his right posterior descending artery, was compressing the right atrium of his heart and causing progressive breathlessness on exertion. Surgeons report that they resolved the problem with an unusual sequence: they first built a new bypass to restore blood flow to the heart muscle, then ligated and removed the old graft and its aneurysm in a single block, all without placing the patient on a heart-lung machine. The case is described in a report published on 16 October 2026 in General Thoracic and Cardiovascular Surgery Cases.

Saphenous vein graft pseudoaneurysm is a recognized but uncommon late complication of coronary artery bypass grafting. A pseudoaneurysm is a rare late complication of coronary artery bypass grafting, and management is particularly challenging when the pseudoaneurysm-bearing graft remains an active source of myocardial perfusion. The authors of the report note that management becomes particularly challenging when the pseudoaneurysm-bearing graft still serves as an active source of myocardial perfusion, meaning the heart muscle downstream depends on that diseased vessel for its blood supply.

In this patient, the diagnostic workup proceeded in stages. Echocardiography first demonstrated a large mass abutting the right atrium. Computed tomography angiography then characterized the lesion precisely: a 10 × 7 × 6 cm partially thrombosed pseudoaneurysm arising from the saphenous vein graft to the right posterior descending artery, with compression of the right atrium. Coronary angiography added the hemodynamic picture that shaped the surgical plan. It showed the pseudoaneurysm filling from the graft, chronic occlusion of the native right coronary artery, patent mammary grafts, and severe stenosis in the proximal portion of the diseased vein graft.

The heart team considered transcatheter exclusion unsuitable because of the distal entry site, calcific graft disease, and ongoing distal right coronary dependence. Coronary angiography demonstrated chronic native right coronary artery occlusion, patent mammary grafts, and severe proximal graft stenosis. A multidisciplinary heart team evaluated whether the pseudoaneurysm could be excluded through a catheter-based approach instead of open surgery. The team concluded that transcatheter exclusion was unsuitable for three reasons: the entry site into the pseudoaneurysm was located distally, the graft had calcific disease, and the distal right coronary circulation remained dependent on flow through the graft.

The surgical strategy that emerged followed the logic captured in the report’s title: revascularize first, resect second. Before touching the pseudoaneurysm, the team performed a redo off-pump saphenous vein grafting to the right posterior descending artery, establishing a fresh conduit to the territory the old graft supplied. Only after this new bypass was in place did they proceed to ligate the pseudoaneurysm-bearing graft proximally and distally and excise it en bloc, removing the aneurysm sac together with the graft as one specimen. After transit-time flow measurement confirmed new-graft function, the pseudoaneurysm-bearing graft was ligated proximally and distally and excised en bloc.

Redo off-pump saphenous vein grafting to the right posterior descending artery was performed before old-graft ligation. By grafting the new vein while the heart continued beating, the surgeons avoided bypass altogether. Transit-time flow measurement confirmed new-graft function before the old graft was ligated.

The patient was discharged on postoperative day 5. The patient was discharged on postoperative day 5. Three-month computed tomography angiography demonstrated a patent new graft without residual pseudoaneurysm. The authors state that the case highlights that graft patency and myocardial dependence should be defined before exclusion of a saphenous vein graft pseudoaneurysm, and that in selected patients, revascularization before graft sacrifice can be performed off pump, avoiding cardiopulmonary bypass while preserving myocardial perfusion.

This is a single case report. The authors state that in selected patients, revascularization before graft sacrifice can be performed off pump, avoiding cardiopulmonary bypass while preserving myocardial perfusion. In this instance, the answer was to build the replacement supply first and remove the failing vessel second, on a beating heart.

Subject of Research: Off-pump surgical management of a giant saphenous vein graft pseudoaneurysm after coronary artery bypass grafting

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

Article References: Rakesh, A., & Saran, N. (2026). Revascularize first, resect second: off-pump excision of giant SVG pseudoaneurysm. General Thoracic and Cardiovascular Surgery Cases, 5(1), Article 46. https://doi.org/10.1186/s44215-026-00273-2

Image Credits: AI Generated

DOI: 10.1186/s44215-026-00273-2

Keywords: coronary artery bypass grafting, saphenous vein graft, pseudoaneurysm, off-pump surgery, coronary angiography, computed tomography angiography, transit-time flow measurement, myocardial revascularization, case report, cardiac surgery, Revascularize, first