Clinical Images

Coronary Artery Tenting After Bypass Grafting: A Key Issue During Percutaneous Coronary Intervention of a Chronic Total Occlusion

J INVASIVE CARDIOL 2019;31(1):E2-E3.

Key words: chronic total occlusion, percutaneous coronary intervention, saphenous vein graft

A 73-year-old man was admitted for progressive angina. He had a chronic total occlusion (CTO) of the mid left anterior descending (LAD) artery that was treated with a saphenous vein graft (SVG) to the LAD and second diagonal branch (D2) in 1983. In 1998, a stent was implanted at the SVG-LAD anastomosis. In 2003, both SVGs were occluded. Left ventricular ejection fraction was 40% and anterior-wall viability was confirmed.

The LAD-CTO showed a proximal blunt stump and ambiguous course, with moderate calcification and about 20 mm in length (Figure 1A; Video 1). Two previous antegrade attempts had failed (Figure 1B). A retrograde approach through a distal epicardial collateral from the right coronary artery (Figure 1C) was planned. A Sion guidewire (Asahi Intecc) was advanced through the collateral, straightening the loop produced by the SVG-LAD anastomosis (Figure 1D). This fact suggested that the graft with more cranial insertion was anastomosed to the D2 instead of the LAD, and the stent was at the SVG-D2 anastomosis (Figure 1E). The SVG produced a cranial tenting of D2 (10 mm from its origin) that distorted its anatomy, producing confusion about the CTO course (Figures 1F and 2A). A Caravel microcatheter (Asahi Intecc) was advanced to the CTO distal cap (Figure 2B); after putting another wire in the first diagonal as a marker, antegrade and retrograde Gaia-2 guidewires (Asahi Intecc) connected in the CTO body, reaching the true proximal lumen with the retrograde one (Figure 2C). An RG3 guidewire (Asahi Intecc) was externalized. After predilation, two drug-eluting stents were implanted at the LAD and D1 with minicrush technique with a good final result (Figure 2D; Video 2). 

This image series shows how bypass grafts may tent the vessel to which they are anastomosed, potentially changing the expected course of the native coronary vessel. This fact must be taken into account during CTO-PCI, and this case emphasizes the importance of careful analysis of coronary anatomy with several angiographic projections.

View the accompanying video series here. 

From the 1Interventional Cardiology Unit, University General Hospital of Ciudad Real, Spain; and 2Interventional Cardiology Unit, Galdakao-Usansolo Hospital (Vizcaya), Spain.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted July 23, 2018. 

Address for correspondence: Alfonso Jurado-Román MD, PhD, Avda Obispo Rafael Torija SN, 13005, Ciudad Real, Spain. Email: