Clinical Images

Retrograde Intervention of a Right Coronary Artery Chronic Total Occlusion Through an Ipsilateral Kugel's Artery Collateral

Koyu Sakai, MD1;  Junichi Omura, MD2;  Masashi Iwabuchi, MD3

Koyu Sakai, MD1;  Junichi Omura, MD2;  Masashi Iwabuchi, MD3

J INVASIVE CARDIOL 2017;29(6):E69-E70.

Key words: chronic total occlusion, retrograde intervention, reverse CART

A 63-year-old man with prior coronary artery bypass graft surgery was admitted with Canadian Cardiovascular Society class III exertional angina. All bypass grafts had been occluded. Diagnostic angiography demonstrated occlusion of the proximal segment of the right coronary artery (RCA) (Figures 1A and 1B) and significant stenosis in the left main coronary artery (LMCA) (Figure 1C). First, we deployed a biolimus A9-eluting stent in the LMCA lesion (Figure 1D).  

Two months later, we attempted to treat the chronic total occlusion (CTO) of the proximal RCA, and performed the retrograde approach using an ipsilateral Kugel’s artery collateral (Figures 1A and 1B). We gently crossed through the ipsilateral Kugel’s artery collateral using a plastic-jacket hydrophilic wire, which was advanced to the proximal end of the CTO lesion (Figure 1E). A second guiding catheter, placed into the RCA ostium, optimized the technical feasibility of reverse controlled antegrade and retrograde subintimal tracking (CART). After successful reverse CART (Figure 1F), we deployed four biolimus A9-eluting stents from the proximal to distal RCA (Figure 1G). At 2-year follow-up, the patient was free of any angina symptoms, with excellent patency of the CTO lesion (Figure 1H).

Kugel described an atrial artery that was called “arteria anastomotica auricularis magna” because of its large caliber, the apparent importance of its anastomotic role, and its consistent occurrence at this site.1 To the best of our knowledge, this is the first case of proximal RCA-CTO successfully recanalized using the reverse CART technique through the ipsilateral Kugel’s artery collateral.


1.    Kugel MA. Anatomical studies on the coronary arteries and their branches. I. Arteria anastomotica auricularis magna. Am Heart J. 1927;3:260-270.

From the 1Department of Cardiology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan; 2the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; and 3the Department of Cardiovascular Medicine, Nephrology and Neurology, Graduate School of Medicine, University of Ryukyus, Okinawa, Japan.

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.

Manuscript submitted October 25, 2016, final version accepted November 2, 2016.

Address for correspondence: Koyu Sakai, MD, Hiroshima City Hiroshima Citizens Hospital, Cardiology, 7-33 Moto-machi, Naka-ku, Hiroshima, Japan 730-8518. Email: