Algorithm for Recanalization of Chronic Totally Occluded (CTO) Native Coronary Arteries Through a Diseased or Occluded Saphenous Vein Graft in Post Bypass Patients.

Jo Dens

doi:10.31579/2641-0419/134

Abstract

Chronic total occlusion (CTO) desobstruction of a native coronary artery in a post coronary artery bypass graft (CABG) patient can be a challenging procedure. In principle, the 3 basic approaches of recanalization of occluded native coronary arteries can be used: antegrade wire escalation (AWE), antegrade dissection re-entry (ADR) and a retrograde technique. On the other hand, a previous implanted saphenous vein graft (SVG) – even when occluded – can be used as a conduit for retrograde access. Moreover, access through a graft might be less complex compared to the use of septal or epicardial collaterals. If the graft is still open or has a tapered stump, this should be considered as a suitable conduit. Literature on recanalization of occluded native coronary arteries trough a diseased or occluded SVG is limited. A flowchart with an algorithm in post CABG patients is proposed and illustrated by 3 clinical cases.

Highlights

About 30 years ago, Kahn and Hartzler performed the first percutaneous coronary intervention (PCI) through a saphenous vein graft (SVG) on a native coronary artery [1]
Diseased or occluded SVGs are suitable for retrograde access in coronary artery bypass graft (CABG) patients, but literature on these procedures is limited
Chronic total occlusion (CTO) desobstruction of a native coronary artery which is bypassed by a diseased or occluded SVG can be performed by the three conventional techniques: antegrade wire escalation (AWE), antegrade dissection reentry (ADR) and by a retrograde technique (Figure 1)

Summary

Introduction

About 30 years ago, Kahn and Hartzler performed the first percutaneous coronary intervention (PCI) through a saphenous vein graft (SVG) on a native coronary artery [1]. CTO desobstruction of a native coronary artery which is bypassed by a diseased or occluded SVG can be performed by the three conventional techniques: antegrade wire escalation (AWE), antegrade dissection reentry (ADR) and by a retrograde technique (Figure 1). A double lumen catheter is advised if the SVG anastomosis is proximal from the distal cap In this case, the native RCA was retrogradely wired through the SVG using a Gaia 3 (Asahi, Japan) and Corsair MC (Asahi, Japan). The final step is to visualize and wire the distal vessel, either through collaterals or through contrast injection with a microcatheter/double lumen side port (Figure 6A). Following the same steps in the flowchart, the first step is to “blindly” wire the SVG towards the native coronary artery with visualization of the collaterals (Figure 8A). Lesion preparation and stenting of the RCA was performed (3.0 x 48 mm + 3.5 x 30 mm, Synergy, Boston Scientific, US) (Figure 15)

Discussion

Findings

Conclusion