Author + information
- Nimit Shah1
Patient initials or identifier number
Relevant clinical history and physical exam
• A 69 years-old man had a CABG 18 years ago
• Admitted with troponin positive ACS
• LIMA to LAD and venous grafts to RCA and first obtuse marginal.
• PCI to RCA graft and native LAD was 3 years ago.
• Non diabetic and being treated for hypertension.
• Good LV function
• On standard secondary prevention therapy includingaspirin, clopidogrel and LMWH
Relevant test results prior to catheterization:
Relevant catheterization findings:
3. Retrograde approach
4. Hybrid approach
Three guide catheters were used
Native RCA (8F femoral access, AL 0.75)
Native left system (6F Left radial access, EBU 3.5)
Venous graft to RCA (6F, right radial access,MPA)
Retrograde visualization done from native left system
RCA wired retrogradely via SVG with the support of corsair.
• Unable to advance corasir, dilatation across the stent struts
• Retrograde Knuckling
• Corsair advanced retrogradely
• 3 guides, antegrade wiring
• Antegrade wiring; Reverse cart; Wire into the retrograde guide; Unable to advance corsair into the retrograde guide hence Corasir removed
• Stent advanced retrogradely; Unable to advance the third stent; Guideliner to advance the stent; antegrade wiring and antegrade picture
• Antegrade wiring to the distal RCA; antegrade stents; Stent across the anastomisis and within the previous stent with the guide liner support; Stent in the ostium; Final result.
• This case highlight complexities of PCI in native vessel CTO’s of patients with Hx CABG.
• Successful use of both the native conduits and venous grafts, using three guide catheters, to deploy stents in the chronically occluded segment
• Knowledge and expertise in performing antegrade,retrograde and hybrid approach crucial to the success of CTO's
• Patient remained symptom free at 6 months
THINK OUTSIDE THE BOX!