2019 Scientific Sessions

Title：Recanalization of SVG-CTO Using Excimer Laser atherectomy free of Embolic Protection Devices Introduction：Adverse clinical outcomes after percutaneous coronary intervention (PCI) in saphenous vein grafts (SVG) have been revealed, The risk of interventional embolization and a high restenosis rate don’t make it recommendable as a first strategy despite advances in therapy including the utilization of embolic protection devices (EPDs). However, unfavorable anatomic characteristics for revascularization of the native coronary artery have to be prompted the intervention of SVG as a last option. Clinical Case ：A 76-year-old female patient with coronary risk factors being hypertension, diabetes mellitus and dyslipidemia admitted to our department for coronary angiography due to exacerbation of angina. CABG have been performed in 2008 because of the myocardial infarction. Electrocardiogram suggested T wave inversion of II III and AVF leads. CAG: 90% stenosis with calcification in the proximal LCX, the proximal LAD and the ostium of RCA were complete occluded. Fortunately the SVG to RCA and LIMA to LAD were patent, but SVG to OM was total occluded and severe stenosis in the proximal LCX, Thus, an attempt to dredge the native vessel LCX seems to be reasonable. A Fielder XT-r guidewire supported by FINECROSS 135cm microcatheter successfully traverse to the distal segment of LCX. Unfortunately, microcatheters and small balloon(1.0×10mm compliant balloon) all failed to through the stenotic lesions. The patient continued with aggravated symptoms of effort angina, Careful observation of the angiography found that competitive blood flow seems to have developed from the distal of OM up to the graft anastomosis. A retrograde approach to reopen the SVG was attempted. Interestingly, the retrograde guidewire traversed the total occlusions lesion into the ascending aorta and fail to acess the antegrade catheter. Meanwhile the antegrade guidewire accomplished through SVG CTO to the LCX-OM branch under the reference of retrograde wire. Simultaneously, A gentle Tip-injection authorized the guidewire position into true lumen and distal intra-luminal thrombus. Firstly, 0.9mm laser catheter was used in the procedure at fluence and repetition rates were 60mJ and 60Hz and finally cross the lesion, 2 DESs(Excel 2.75×36mm/3.0×33mm) were implanted from the distal to ostial saphenous segment and perfectly post dilated by 3.0×12mm non-compliant balloon (20-24atm). The optical coherence tomography(OCT) was used during excimer laser coronary angioplasty. A successful angiographic result with TIMI grade III flow was achieved and no-flow was not found. There were no electrocardiographic changes and adverse events in the periprocedural Discussion:we present this successful cases of total occluded SVG by excimer laser without distal protection device and finally treated with drug-coated stents（DES),there are several points that are worthy of emphasis, firstly, low penetration force and polymer jacket guidewire (Fielder XT/Pilot 50 ) should be preferred, with the purpose of increasing the chance of tracking the vessel and reducing the risk of perforation. Secondly, select the appropriate laser catheter and slow advancement of action should also be concerned about this aspect. Finally, Strictly observe the principle of the procedure and the patience and perseverance of operator are also an important role in the clinical outcomes.