Right coronary artery chronic total occlusion revascularization by knuckle technique through right gastroepiploic artery graft

Abstract

Sirs:Angina pectoris following bypass surgery is caused bygraft failure or new lesions developing in the native coro-nary artery. Right gastroepiploic artery (RGEA) has beenshown to have a good short- and long-term patency whenanastomosed to the right coronary artery (RCA). Long-term patency is 80–90% at 5 years; however, it decreasesto approximately 62% at 10 years [1].Many reports suggest that successful revascularizationof chronic total occlusion (CTO) subtending viable myo-cardium determines a more favorable long-term outcomewith survival enhancement and improvement in quality oflife [2, 3].We present a case of RCA CTO recanalization usingretrograde approach through RGEA graft.Case reportA 64-year-old man ex smoker with hypercholesterolemia,type II diabetes mellitus, mild hypertension underwentcoronary artery bypass graft (CABG) surgery for anteriormyocardial infarction in 1997 with left internal mammaryartery (LIMA) on left anterior descending (LAD) andRGEA on posterior descending artery (PDA). Since 2003the patient referred onset of angina at medium workload;he performed an exercising test which was interrupted at75 W for V3–V6 down-sloping ST depression and non-sustained ventricular tachycardia. For this reason thepatient was referred for a new coronary angiography(CAG) which showed: LIMA patent, distal LAD withsevere stenosis, RCA proximal occlusion, RGEA patentwith disease at the anastomosis and in native distal RCA(crux) (Fig. 1a–b). The patient was referred for a newCABG in 2004; however, he refused this treatment and hestarted optimal medical therapy. After 5 years, due tosymptoms worsening, the patient underwent CAG (May2009) which showed a comparable angiographic pattern tothe previous one. Thus, the patient underwent a stressmyocardial scintigraphy which showed severe reversibleinfero-lateral hypoperfusion with a normal left ventricularfunction. Thereafter it was decided to attempt RCA per-cutaneous revascularization in June 2009.Unfractionated heparin (5,000 units intravenously) wasadministered. A 7 French Amplatz left and a 7 FrenchJudking right guiding catheter were used to engage RCAostium and RGEA graft, respectively. Contrast meaninjection from RGEA confirmed severe disease at theanastomosis and distally native RCA. The lesion was firstapproached by antegrade with a soft-tapered polymericguidewire (Fielder XT, Asahi) and a microcatheter (Fine-cross, Terumo) which was advanced up to the mid-RCA.As this guidewire was not able to progress any further, itwas exchanged using the microcatheter with an interme-diate-stiffness one (Medium guidewire, Asahi). The Med-ium guidewire was able to advance up to the mid-distal partof the vessel where it stopped due to severe calcifications.Thus, a soft-tapered polymeric guidewire (Fielder XT,Asahi) was inserted with a Corsair microcatheter (Asahi)through RGEA by retrograde. This wire got through thesevere disease at the anastomosis; however, it stuck in the