Case 220: Manual of CTO PCI - Don't stent across the SVG distal anastomosis!

A patient was referred for PCI of a native right coronary artery CTO due to recurrent failure of a saphenous vein graft to the PDA. A stent had previously been placed across the SVG distal anastomosis with the PDA. The side-BASE technique was used to advance a knuckled Gladius Mongo wire extraplaque, while avoiding an acute marginal branch located at the distal cap. Despite using multiple penetrating guidewires and various microcatheters, including the Venture, a guidewire could not be advanced through the previously placed stents at the SVG distal anastomosis even after doing intravascular lithotripsy in the native vessel at the anastomosis that had under-expansion. Using the Stingray balloon and the “stick and drive” technique a Gaia Next 3 was advanced into the distal true lumen in the right posterolateral. IVUS showed that re-entry had actually been achieved through the previously placed stent at the SVG anastomosis. Stents were placed in the RCA all the way to the right posterolateral, resulting in occlusion of the PDA. A wire was advanced through the SVG-PDA into the right posterolateral, followed by kissing balloon inflation that restored antegrade TIMI 3 into the PDA, achieving a nice final result.

[@shangz0216]

Thanks for the educative case presentation.

[@drmz2007]

Excellent case sir Good learning points 👏

[@arhipmatusov8823]

Thanks! That's really a very complex case, so congratulations with the success! Previously I've stented through distal anastomosis twice or thrice (though I avoid doing it if possible). I remember one of the cases when I've implanted a stent from LIMA to LAD, and then made a "provisional" angioplasty to the proximal side of the anastomosis, opening the struts. It was an intuitional decision that time. ;) But I think it could make things easier if someone would decide to reopen the native LAD for that patient.

[@maisamtaherian986]

Thanks you very much. Would you tell us, is it useful to use angel microcatheter like supercross to facilitate wiring the PDA?

[@happyhearts4254]

Manos this is such an interesting case..SVG to RCA is inserted into RPDA, not the distal RCA itself..and this graft has kind of pulled RPDA towards it..this is why this case was difficult..

[@happyhearts4254]

And previous stent has gone SVG->PDA->PLV..

[@happyhearts4254]

drive.google.com/file/d/1V1XofWawhG0cnb0m8q24k9uU88PuhK5w/view?usp=drivesdk

[@mahmoud_elrayes]

Excellent case. Could you call this technique as "retrograde culotte" as you operating from the 2 branches(distal RCA & SVG) toward the confluence of these 2 vessels( RPLB )? Please you opinion. Thanks.

[@manosbrilakis]

Great point - I would actually call it "provisional with retrograde salvage"! We stented across anastomosis and when flow was lost in the PDA, we wired retrogradely into the right posterolateral and did kissing balloon inflation. If we had placed a 2nd stent, it would have been a "retrograde culotte"!

[@mahmoud_elrayes]

@@manosbrilakis Great. Is the new stent inside the old stent( across the anastomosis from SVG to RPLB) as you puncturing through it? Thanks again for this case.