Atypical Chest Pain and a Blood Blister: More Than Meets the Eye

A 76-year-old man who had undergone coronary bypass surgery15 years previously presented with a 1-week history of atypical chest pain and a “blood blister” on his chest (Fig. 1A). Oddly, he reported a small sternal wound concern 2 years previously that had been treated with superficial debridement and sternal wire removal by a local general surgeon. His medical history was significant for lung adenocarcinoma treated with resection. Physical examination revealed a 2-cm pulsatile purple skin lesion at the inferior aspect of the sternum (Fig. 1A; Video 1 , view video online). He was afebrile without any signs of systemic infection. Computed tomography demonstrated a 12 × 10 × 8 cm ruptured saphenous vein graft (SVG) pseudoaneurysm, extending through the sternum, contained at the level of the skin (Fig. 1, B and C). Coronary angiography demonstrated a patent but ruptured SVG to the posterior descending artery (Fig. 1D, Video 1 , view video online), and echocardiography demonstrated a large mass compressing the right atrium and ventricle (Fig. 1, E and F). Percutaneous treatment with covered stents was contemplated but ultimately regarded as likely to fail because of the extensive distance between the 2 ends of the SVG. At emergency operation (Fig. 2), cardiopulmonary bypass was initiated with femoral access to allow safe sternal re-entry. The pseudoaneurysm was entered immediately, with the SVG appearing severed in its midportion with a normal-calibre SVG on either side. Under beating heart conditions, control of the proximal and distal ends of the ruptured SVG averted massive hemorrhage but resulted in immediate ST-elevation and inferior-wall akinesia. A temporary carotid shunt placed between the 2 ends of the SVG restored flow and immediately resolved the ST-elevation and ventricular dysfunction (Video 2 , view video online). The pseudoaneurysmal sac was debrided completely and a new SVG bypass was constructed. The patient did well and had an uneventful hospitalization. Tissue cultures were positive for Staphylococcus aureus, prompting initiation of antibiotic therapy. This patient did not appear to have a typical atherosclerotic degenerated SVG aneurysm but rather an acutely disrupted SVG likely from infection or mechanical disruption, or both. Hypervigilance and further imaging investigation helped clarify this patient's “blood blister” and averted a major disaster that could have occurred after further local wound exploration and debridement.