Clinical Images

Triple-Access Retrograde Chronic Total Occlusion Intervention Through Vein Graft and Epicardial Collaterals

Ioannis Tsiafoutis, MD; Catherine Liontou, MD; Athanasios Antonakopoulos, MD; Konstantina Katsanou, MD; Michael Koutouzis, MD; Apostolos Katsivas, MD

Ioannis Tsiafoutis, MD; Catherine Liontou, MD; Athanasios Antonakopoulos, MD; Konstantina Katsanou, MD; Michael Koutouzis, MD; Apostolos Katsivas, MD

J INVASIVE CARDIOL 2020;32(6):E172-173.

Key words: chronic total occlusion, saphenous vein graft


A 72-year-old diabetic man with history of myocardial infarction and triple coronary artery bypass surgery presented with exertional angina. Stress echocardiogram revealed reversible ischemia of the inferior-posterior left ventricular wall. Coronary angiogram showed severe proximal left anterior descending (LAD) and left circumflex lesions with patent left internal mammary graft to LAD and saphenous vein graft (SVG) to obtuse marginal (OM) branch, chronic total occlusion (CTO) of the proximal right coronary artery (RCA), and occluded SVG to RCA. The OM supplied epicardial collaterals to the distal RCA (Figure 1). Based on the patient’s symptoms and stress echocardiographic findings, a decision was made to recanalize the totally occluded RCA via retrograde approach through the SVG to the OM. 

Due to inadequate visualization of the epicardial collaterals and distal RCA via SVG, triple-access was used (cannulation of both left and right coronary arteries and SVG through right femoral, right radial, and left ulnar artery) and injection via left main. Although a wire was successfully advanced retrogradely through the epicardial collateral, the attempt for reverse controlled antegrade and retrograde tracking failed (Figure 2). Subsequently, an antegrade approach successfully crossed the CTO using the “just marker” technique. Finally, three drug-eluting stents were implanted with good angiographic result (Figure 3; Video 1). 

In selected CTO cases, triple access may facilitate the retrograde approach, allowing optimal collateral visualization.


From the Department of Cardiology, Athens Red Cross 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 October 23, 2019.

Address for correspondence: Ioannis Tsiafoutis, MD, 1st Cardiology Department, Athens Red Cross Hospital, 1 Athanasaki St 11521, Athens, Greece. Email: tsiafoutisg@yahoo.com

/sites/invasivecardiology.com/files/articles/images/E172-E173%20Tsiafoutis%20JIC%20June%202020%20wm.pdf