Case 206: Manual of CTO PCI - Giant SVG aneurysm

A patient presented with NSTEMI and was found to have a large aneurysm in a SVG to OM2 and a severe lesion in a SVG-PDA. The patient was not a surgical candidate. He underwent successful PCI of the SVG-PDA, followed by an attempt to recanalize the native OM2 and then occlude the aneurysmal SVG.
Initial attempts for retrograde crossing failed due to poor support (wire impenetrable distal cap - guide extension was bowing into aneurysm when pushing wire). Antegrade attempts succeeded in advancing a knuckled Gladius Mongo into OM1, but the lesion was balloon uncrossable. We used the “mother-daughter-granddaughter” technique to get more support over the retrograde system and allowed a knuckled Gaia Next 3 to be advanced next to the antegrade guidewire. After using the “BASE” technique over the antegrade wire we successfully completed reverse CART and externalized a retrograde guidewire. We stented from the left main into the OM2 and postdilated with a 3.5 mm NC balloon, which fractured upon withdrawal. We advanced a retrograde Turnpike LP in at attempt to remove the externalized guidewire which caused longitudinal deformation of the distal stent. We balloon with increasingly larger balloon delivered retrogradely and deployed another stent covering the deformed stent. We were then able to withdraw the externalized guidewire and remove the antegrade guide extension along with the balloon fracture. We ended up coiling the proximal and distal segment of the aneurysmal SVG.

[@drmz2007]

Near impossible case Excellent 👏👏👏

[@amjadalmendilawi5328]

559 min is more than 9 hours. I Wonder how was the patient doing during the procedure, how did you manage sedation , fluid , urination , anticoagulation ! That’s a formidable job . And how did you manage yourself and your staff .

[@manosbrilakis]

This was clearly a very long procedure and we considered stopping several times. Foley catheter was placed and IV fluids were given. ACT was held >300 sec throughout the procedure. Some of the staff (RN, techs) changed during the case.

[@ahmettemiz2528]

Your longest case was 16 hours lenght so this case is supposed to be fairly easy for you because you are the king.💪

[@usetherightbrain.]

You Sir are second to none

[@shangz0216]

Thanks for the excellent case presentation.

[@drdeepakonkar]

Great sir, nice demonstration of CTO techniques.

[@eyasalmousaable]

Great case could a graft stent in the SVG be an option ?

[@manosbrilakis]

Yes this is another option - one of the challenges is the difference in the size of landing zones on both sides of the aneurysm.