A Case Study on Chronic Total Occlusion Interventions

A 73-year-old man with prior coronary artery bypass graft surgery (CABG) presented with exertional angina and was also found to have an expanding saphenous vein graft (SVG) aneurysm (Video 1) and a patent left internal mammary artery graft. The patient was turned down for redo surgery due to high risk. An initial attempt for right coronary artery chronic total occlusion percutaneous coronary intervention (CTO PCI) failed (Video 3), and he was referred for PCI of the right coronary artery (RCA) CTO (Video 2). Triple injection (through the left main, right coronary artery, and saphenous vein graft to the right posterior descending artery [PDA], Video 4) revealed a long occlusion length without any septal collaterals to the right PDA. After retrograde CTO crossing failed, antegrade crossing was attempted (Video 5). A CrossBoss catheter was advanced into an acute marginal branch (Video 6), and redirected to the distal right coronary artery using a knuckle wire (Video 7) until a re-entry zone was reached (Video 8). Re-entry was challenging, but was successfully achieved using the Stingray balloon and guidewire (Video 9 and 10). After implantation of several drug-eluting stents, the right coronary artery was successfully recanalized (Video 11).

Video 1: SVG Aneurysm

Video 2: RCA CTO

Video 3: Failed PCI Attempt

Video 4: Triple Injection

Video 5: Retrograde Attempts via SVG Failed - Clarifying Proximal Cap

Video 6: Knuckle – Then CrossBoss

Video 7: Knuckle Redirect

Video 8: Bobsled

Video 9: Repeat Re-Entry Attempt

Video 10: Re-Entry Success

Video 11: Final

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: Aneurysm, Angina Pectoris, Catheters, Coronary Vessels, Drug-Eluting Stents, Mammary Arteries, Saphenous Vein, Angiography

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