Patient T. 14.04.1948 year of birth, height 176, weight 94kg.
Risk factors: Arterial hypertension, smoking up to 20 cigarettes.day, hyperlipidemia.
Hystory - MI 2004 y,2011y, CABG - 4 in 2004, 2011, stenting venous bypass to CX. At admission, progressive angina is recorded, ST segment instability on ECG (depression up to 1.5mm in II, III, AVF)
ECHO - hypokinesia of the apex-lateral and basal segments with a total preserved EF - 55%. Creatinine 104,4mmol / l, blood glucose 6,0mmol / l, Troponin negative.
Coronaroangiography: RCA - chronic occlusion, bypass
occluded (coro 2011), LAD - critical stenosis in the middle third,
is filled from internal thoracic artery. CX - chronic occlusion, diffusely changed. The jumping, previously stented bypass to the DB of the LCA and CX is critically narrowed in the distal third to 90%. Stented segment patent.
Strategy: Because of old bypass graft, a previously implanted stent in the proximal part of the bypass, it was decided to recanalize CTO of native CX.
Bifemoral access using 45 cm introducers and 7 F catheters with cannulation of the venous bypass and left coronary artery was used. With bilateral injection, a short-calcified site of CX occlusion is determined (Figure 1).
We started antegrade recanalization with use of “Corsair” microcatheter 130 cm and “Filder XTR”, then “Gaia 2”. After recanalization occlusion part with wire it was not possible to cross the occlusion site with the microcatheter. The retrograde approach was started, through a venous bypass, using a 150 cm “Corsair” microcatheter and a “Gaia 2” guidewire. The wire was passed into the proximal sections of the LCA and fixed in the antegrade guide catheter using the Trap technique with a balloon catheter 2.5 mm. Nevertheless, even with strong system fixation it was not possible to cross a retrograde microcatheter via a calcified occlusive segment. We change the microcatheter for low profile “Caravel” and “Fine cross” without any results (Figure 2).
The next step after the removal of the retrograde instruments
it was used “Guidezilla” 6F guide catheter extension, dilatation
with the 1.5 “Trek” balloon catheter (Figure 3), and after that
retrograde microcatheter could cross CTO site and was fixed
into an antegrade guide and an externalization procedure was
performed using the RG 3 guidewire (Figure 4). Further, after
balloon angioplasty with a balloon catheter of 2.5 mm, an attempt
was made to implant the stent in the CX, but in view of the
calcified site, the stents could be implanted only with the use of
the “Guidezilla” 6F catheter extension in antegrade fashion.
After the stenting of the CX with 2x stent “Xience” flow was
completely restored (Figure 5). At control coronaroangiography
the competitive blood flow in the distal artery through a stenotic
venous bypass still existed. We refrained from bypass embolisation
in view of its «jumping character» and the fear of occlusion of the
blood flow to the DB of the LCA.
The patient’s condition was stabilized, ECG changes were
released, discharged for 3 days.
a. In case of old diseased venous bypass in patients after
CABG CTO recanalization of native arteries recommended.
b. One should be prepared for the fact that the occlusal
segment of the artery after CABG is often calcified, and it
requires considerable effort and material for its recanalization.
c. The venous bypass can be successfully used for
retrograde recanalization, IVUS examination can assess the
state of the bypass and the presence/absence of thrombotic
masses, a potential source of distal embolization of the
d. The issue of postoperative embolization of venous
bypass as a source of competitive blood flow remains at the