冠動脈バイパス後静脈グラフト狭窄に対するＰＣＩ　ｆａｉｌｕｒｅの１緊急手術例 Emergency Reoperation for Vein Graft Rupture Caused by PCI Failure

症例は68歳,女性.狭心症に対しCABG(HTA-LAD,GEA-4PD,SVG-#9-#14 sequential)を施行した.術後14ヵ月後に胸部不快感が出現,心カテーテル検査で静脈グラフトと#9との吻合部に90%狭窄を認め,PCI施行となった.5mmのバルーンにて14気圧までinflateしたところ,狭窄は解除されたが,造影剤の漏出を認め,グラフトruptureと診断した.バルーンをinflateし,止血を試みたが,不可能であったため,緊急手術となった.左側方開胸にて心嚢に到達,静脈グラフトのruptnre部はすでに止血されていた.グラフトと#9との吻合部の前後でグラフトを結紮,あらたに採取した静脈グラフトにてこの間を飛び越えるようにバイパスした.術後造影にてグラフトの開存が確認された.エコー上側壁の運動低下を認めたが,EFは67%と良好であり,狭心症も消失した.

A 68-year-old woman on chronic hemodialysis was admitted to our hospital for further evaluation because of recurrent angina 14 months after coronary bypass surgery (left internal thoracic artery-left anterior descending artery (LITA-LAD), gastro-epiploic artery-4 posterior descending artery (GEA-4PD), saphenous vein graft-#9-#14 sequential (SVG-#9-#14 sequential)). On coronary angiography, a localized 90% stenosis of the vein graft was present at the anastomosis with the diagonal branch of the native coronary artery. Although the lesion was relieved with a 5mm balloon catheter inflated to 14 atmospheres, contrast injection demonstrated extravasation of dye into the pericardial space, indicating vein graft rupture. Repositioning the inflated balloon across the rupture site for hemostasis was unsuccessful, and the patient was transferred to the operating room. Emergency reoperation was accomplished through a left lateral thoracotomy without cardiopulmonary bypass. Although hemorrhage was not noted at the rupture site, the vein graft was ligated at the proximal and distal portions of the rupture, followed by a new vein graft bypass. Postoperative cardiac catheterization clearly demonstrated the patent graft. Although localized hypokinesis was observed in the lateral wall on postoperative echocardiography, the left ventricular ejection fraction was 67%, her activity level was good, and she had no angina.