Monthly Case: Early Graft Closure

Safe with notes
The case was of a middle aged man who died suddenly two weeks after a surgery. One of the photographs shows the cause of death. The other photograph from the same patient shows a similar process, but was not the cause of death.

Case discussion:
The photographs show grafts to the heart. These were grafts from a coronary artery bypass procedure. The grafts came from a vein in the leg (saphenous vein) and were attached to the heart to allow blood flow around blocked coronary arteries. The grafts have been cut open to see along the length of their insides.

The bottom graft shows the cause of the death. This graft is completely blocked by the clot seen at the right. The clot appears as a red tube inside the graft. It blocked blood flow from getting completely through the graft to where it needed to go – the heart muscle. It was as though the heart was functioning without this graft at all.

This was a sick heart with a recent serious heart attack that prompted the bypass surgery emergently. The graft was critical to the patient’s health and life.  Without the open graft and the blood flow to the heart, the patient died.

The top photographs shows a small amount of clot healing onto the inside of the graft.  It’s not enough clot to block the blood flow in the graft, but is the same process. This clot is brown and not red because it is starting to heal and scar, which changes the color.

To the left of the clot in the top photo is a hole surrounded by small sutures.  This is called a “side anastomosis.”  This graft was used twice.  Blood flow passed through the side anastomosis to a blood vessel there; and blood flow passed through the end of the graft (all the way at the right) to a blood vessel there.  Often, grafts can be used to bypass more than one blocked vessel.

Early graft closure from clot (thrombosis) is a known, but rare complication of coronary artery bypass grafts.  It’s unrelated to the technique of the surgery or any intraoperative factors, but just a part of the body’s reaction that can sometimes happen to the graft itself.

Meaning to the family:
In this case, while it was helpful to know that the graft closure was “no fault” of the surgeon, the patient had tell-tale signs of trouble during recovery after hospitalization (shortness of breath and fainting) that were not attended to. This was a complicated post-operative story to sort though. The autopsy was helpful to the family by clarifying the cause of death and its relationship to natural processes, the surgery and post-operative care.

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