2020 Scientific Sessions

Title:
STEMI from Acute Saphenous Vein Closure with Successful Retrograde Recanalization of Chronic Total Occlusion of Native Right Coronary Artery

Introduction:
ST elevation Myocardial Infarction (STEMI) from saphenous vein graft (SVG)closure with intervention is associated with high short- and long-term mortality and worse outcomes than native vessel intervention.

Clinical Case:
64 yo female with prior coronary artery bypass graft (CABG) including (LIMA-LAD, SVG-OM, SVG-diagonal and SVG-RCA) who presented with chest pain for half hour at rest. EKG consistent with IWSTEMI therefore taken emergently for coronary angiogram which revealed patent LIMA-LAD, patent SVG-OM and occluded SVG-diagonal graft. Native RCA had a prior ostial stent with in-stent CTO and left to right collaterals. SVG-RCA was occluded with a large thrombotic burden and TIMI-0 flow.

Discussion:
Revascularization of SVG graft, with balloon angioplasty and mechanical thrombectomy failed to restore distal native vessel flow and stenting was not optimal due to SVG and native vessel size mismatch. Retrograde recanalization of native RCA via thrombotic graft was attempted next. Retrograde wire escalation was employed, and CTO wire externalized with gooseneck snare device after crossing proximal cap. Native RCA was treated with three overlapping Everolimus drug eluting stents (Figure 1).

Conclusions: SVG graft intervention during STEMI can be challenging from high thrombotic burden, risk of distal embolus and SVG to native vessel size mismatch for stent implantation. We present a challenging case of retrograde recanalization of native RCA CTO after balloon angioplasty and mechanical thrombectomy of SVG failed to restore native distal vessel flow.