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Relevant clinical history and physical exam
This 70-year-old male had the history of coronary artery disease status post coronary artery bypass graft, diabetes mellitus, hypertension and dyslipidemia. He complained of effort related dull chest pain since 3 months ago, which got more frequent for 3 weeks. No referred pain or dyspnea. On physical examination, a surgery scar was on his chest. Otherwise, he was hemodynamically stable and other physical examinations were unremarkable.
Relevant test results prior to catheterization
The hemogram and biochemistry tests were unremarkable. The electrocardiography revealed sinus rhythm and old inferior wall myocardial infarction; the chest x ray disclosed surgical wire retention. The echocardiogram showed preserved left ventricular systolic function but mild inferior wall hypokinesis. The Thallium scan revealed viable and non-viable tissue in the inferior wall.
Relevant catheterization findings
The 1st coronary angiography revealed coronary artery disease with triple vessel disease post coronary artery bypass graft; left internal mammary artery to left anterior descending artery failure and one saphenous vein graft to right coronary artery (RCA) failure. The RCA was diffuse atherosclerotic with about 60% stenosis at orifice, a long segmental lesion up to 90% stenosis at proximal and middle part and about 50% stenosis at distal part.
2nd: critical stenosis and one aneurysm at the RCA.
The 1st attempt
1. A SAL1 guiding catheter to engage right coronary artery (RCA) orifice.
2. The Fielder FC wire was used but severe dissection with TIMI 1 flow was noted when crossing the critical stenosis.
3. The Fielder FC wire could not enter the true lumen. A Run through hyper coat wire as the parallel wire technique but failed.
4. A Ultimate Bros 3 wire via the Fine cross micro catheter still could not enter the true lumen.
5. To avoid worsened dissection, we closed the procedure. The patient was hemodynamically stable then.
The 2nd attempt (2 months later because the angina got more frequent. Critical stenosis and one aneurysm at the RCA)
1. A SAL1 guiding catheter to engage RCA orifice.
2. The Fielder FC wire via the Minnie micro catheter could not pass the RCA critical lesion.
3. We used the balloons (1.5 mm and 2.5 mm) to dilate the proximal RCA and used the parallel wire technique but still failed to pass the lesion.
4. The angiography showed collateral vessels from left circumflex artery (LCX) to RCA.
5. We tried retrograde approach from LCX; a Sion wire and one Sion Blue wire alternatively within a Corsair micro catheter were used.
6. The Sion wire crossed the collateral's and passed through the critical RCA lesion by retrograde approach.
7. We changed the wire to RG3 for externalization and the Fielder FC wire to RCA.
8. The stents (3.0 mm and 2.5 mm) were deployed at proximal to distal RCA after the balloon angioplasty.
9. The final angiorgraphy showed good results with RCA TIMI 3 flow
In this patient with coronary artery disease post coronary artery bypass graft, we used the general antegrade approach for severe RCA lesion initially. However, we could not pass through the critical lesion and dissection happened unfortunately. For the second attempt of coronary intervention, we tried antegrade approach again but still failed. Therefore, we chose another road less used, the retrograde approach, and that made all the difference. The stent deployed at the RCA smoothly and the final angiography showed good results. Retrograde rescue could be a solution to antegrade dissection.