J INVASIVE CARDIOL 2019;31(2):E43.
Key words: coronary tortuosity, deep guide intubation, high-risk angioplasty, saphenous vein graft
A 66-year-old man with refractory angina was admitted for percutaneous coronary intervention (PCI) through a tortuous saphenous vein graft (SVG) sequentially anastomosed with a diagonal and a first marginal branch (OM1). Our target was a critical stenosis at the retrograde limb of OM1 proximal to SVG anastomosis; stent delivery to our target lesion mandated tracking through sequential angulations (Figure 1A; Video 1).
After engaging the SVG with a 6 Fr JR4 guide catheter (GC), this slaloming anatomy was negotiated with a Pilot-50 guidewire (Abbott) supported by a FineCross microcatheter (Terumo) (Figure 1B). However, we were unable to deliver a short, 2.5 x 12 mm zotarolimus-eluting stent past the SVG-OM1 anastomosis. Attempts to exchange the Pilot-50 with a supportive GrandSlam guidewire (Asahi Intecc) failed due to guidewire prolapse at the anastomotic bend. We eventually delivered the stent over a standard BMW wire (Abbott) after carefully intubating the GC very deeply into the SVG to optimize active support (Figure 1C;Video 2); a second BMW was utilized as a buddy wire. We obtained an excellent angiographic result without residual stenosis or SVG injury (Figure 1D;Video 3).
PCI on the retrograde limb of a bypassed coronary artery through an SVG can be challenging. Extreme angulations and bends at the anastomosis pose great difficulty during wiring and delivery of equipment to a stenosis located proximal to the anastomosis due to poor support. GC extension (mother-and-child) may be helpful in such scenarios. In more demanding cases, complex techniques such as double-GC extension (mother-and-child-and-grandchild technique) may be employed, but these techniques carry a higher risk of dissection. In our case, we enhanced our GC’s support and delivered a stent on the retrograde limb of the OM1 with very deep intubation of the GC into the SVG and use of a buddy wire, which is a cheaper and relatively safer maneuver. Proper selection of the type and size of the GC and meticulous attention to the pressure waveform in order to avoid ischemia or dissection of the graft are mandatory during this technique.
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From the 11st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece; and 2Department of Cardiology, Laiko Hospital, Athens, Greece.
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 September 4, 2018.
Address for correspondence: Konstantinos Aznaouridis, MD, PhD, 1st Department of Cardiology, Hippokration Hospital, 114 Vas. Sofias Avenue, 11527 Athens, Greece. Email: firstname.lastname@example.org