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Evaluation of Patients after Coronary Artery Bypass Surgery: CT Angiographic Assessment of Grafts and Coronary Arteries¹

¹ From the Department of Radiology (K.N., P.M.T.P., P.J.d.F.) and Thoraxcenter, Department of Cardiology (K.N., B.J.R., R.J.M.v.G.), Erasmus Medical Center, Dr Molewaterplein 40, Room D 220, Rotterdam 3015 GD, the Netherlands. Received July 21, 2002; revision requested September 26; final revision received March 24, 2003; accepted April 16. Address correspondence to K.N. (e-mail: koennieman@hotmail.com).

View larger version (113K): [in a new window]   Figure 1. Arterial and venous bypass grafts. Images obtained with contrast-enhanced multi-detector row CT angiography (A, E-I, maximum intensity projections; D, three-dimensional volume rendering) and corresponding conventional angiography (B, C) show a left IMA graft (LIMA) connected to the left anterior descending coronary artery (LAD). Additionally, a venous graft (SVG) runs from the aorta to the diagonal branch (D1), with consecutive jumps to the posterolateral branch (RPL) and posterior descending coronary artery (PDA). Surgical clips (arrowheads) and a bypass indicator (arrow in D, E) appear as bright structures. GCV = great cardiac vein, RCA = right coronary artery. Arrows in I indicate location of labeled right coronary and posterior descending coronary arteries.

View larger version (142K): [in a new window]   Figure 2. Venous graft disease. Images obtained with contrast-enhanced multi-detector row CT angiography (A, three-dimensional volume rendering; B, curved multiplanar reconstruction) and corresponding conventional angiography (C, D) show an arterial and venous bypass graft. The nondiseased left IMA graft (LIMA) is anastomosed to the left anterior descending coronary artery (LAD). A venous graft (SVG) originates from the aorta and is anastomosed to the second diagonal branch (D2). The graft segment between the second and first diagonal branch (D1) shows a substantial stenosis (arrow). Distal to the first diagonal branch the venous graft is completely occluded (arrowhead), which is confirmed with conventional angiography (D, 20° left anterior oblique, 30° caudal angulation).

View larger version (113K): [in a new window]   Figure 3. Venous graft and coronary artery disease. Images obtained with conventional angiography (A, 90° left anterior oblique; B, 30° right anterior oblique; C, 30° right anterior oblique; D, 60° left anterior oblique; E, 0° left anterior oblique and 30° cranial angulation) and contrast-enhanced multi-detector row CT angiography (F, G, three-dimensional volume rendering; H, maximum intensity projection) show a substantial lesion (curved arrow) detected at the proximal anastomosis of the venous graft (SVG) near the aorta, as well as two low-grade lesions (arrowheads) further down the first segment. Located after a nonstenosed second segment, between the second diagonal branch (D2) and the marginal branch (RM), the final segment between the marginal branch and the posteriolateral branch was found to be occluded (thick white arrow in B, bottom of G). Assessment of the native coronary system revealed occlusions in both the proximal right coronary artery (RCA) (thin white arrow) and the left circumflex coronary artery (LCX) (thin black arrow). The left main coronary artery is borderline substantially stenosed (thick white arrow in C, top of G, H), and an additional lesion is seen in the distal left anterior descending coronary artery (LAD) (thick black arrow). The middle segment of the left anterior descending coronary artery was considered nonassessable due to extensive calcium deposits. D1 = first diagonal branch, RVOT = right ventricular outflow tract, IM = intermediate branch.

View larger version (134K): [in a new window]   Figure 4. Repeat CABG. Images obtained with conventional angiography (A, 45° left anterior oblique with cranial angulation and injection of contrast agent in left main coronary artery; B, 30° right anterior oblique with caudal angulation and injection of contrast agent in left main coronary artery; C, 90° left anterior oblique with injection of contrast agent in right coronary artery) and contrast-enhanced multi-detector row CT (D, three-dimensional volume rendering; E-G, maximum intensity projection; H, curved multiplanar reconstruction) after a complex repeat CABG procedure. The initial bypass procedure consisted of grafting a left IMA graft (LIMA) via the diagonal branch (D1) to the left anterior descending coronary artery (LAD); the last segment of the graft was occluded. Selective angiography of the left IMA graft could not be performed. The proximal segment of the sequential venous graft (V1) to the distal right coronary artery (RCA) and marginal branch (RM1) was occluded, leaving only the conduit between the RCA and the RM1 patent. One year after the initial procedure, an additional venous graft (V2) was placed from the aorta to the LAD, the remaining segment of the first venous graft segment between the RM1 and the RCA (VV), and finally a marginal side branch (RM2). Within 1 year, the patient returned with complaints of angina, and occlusion of the first segment of V2 between the aorta and the LAD was detected. The metal artifacts (arrowheads, D) caused by the metal indicators at the aortic root reveal the original proximal anastomoses of the occluded grafts. Arrows indicate locations of labeled vessels. RM = marginal branch, CX = circumflex coronary artery, RVOT = right ventricular outflow tract, GCV = great cardiac vein.