Retrograde-Antegrade Left Main Coronary Artery Stenting

Figure 1. AP view showing total occlusion of the left main artery.
Figure 2. RAO view documenting retrograde wire crossing of the left main artery into the aorta.
Figure 3. Angiographic view of the retrograde wire into the aorta after injection of contrast.
Figure 4. Shallow RAO view documenting antegrade and retrograde wires into the left main artery.
Figure 5. Final result.
Author(s): 

Ricardo I. Vicuna, MD, Paul Silverman, MD, Bruce Abramowitz, MD, FACC, FSCAI

Discussion. This is a case that reflects a frequent problem in current interventional practice: percutaneous intervention in post-bypass patients. It required an innovative method in order to recanalize a recent total occlusion of the LM artery with an origin that could not be determined in an antegrade fashion, but was successfully reached retrogradely. There were no major problems crossing the lesion once the origin was confirmed, although the literature reports this as the first-line problem associated with chronic total occlusion (CTO),11,12 with success rates that range from 40–81%. It proved to be a safe intervention on a protected LM occlusion. The patient received a sirolimus-eluting stent which, based on the current literature,13 may be an alternative therapy to surgical revascularization of patients with LM disease. Valgimigli14 reports an HR of 0.52 for major cardiovascular events in the drug-eluting stent (DES) group compared with bare-metal stent (BMS) patients who underwent intervention of the LM coronary artery (median follow up of 503 days). This finding is consistent with that of Chieffo15 who documented a 20% incidence of MACE at 6 months in LM DES patients compared with 35.9% in LM BMS patients. Both studies showed the efficacy of DES compared with BMS in this group of patients. The case described here demonstrates an unusual retrograde-antegrade approach to achieve a successful result in recanalizing a recent “flush occlusion” of the LM which could not be identified in the usual antegrade-only approach.

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