Retrograde Left Circumflex CTO PCI Through an SVG: Deflection Technique, DK-Crush, and Occlusion of the SVG
Presenter
Michael S Megaly, M.D., FSCAI, Henry Ford Hospital, Bossier City, LA
Michael S Megaly, M.D., FSCAI, Henry Ford Hospital, Bossier City, LA
Title
Retrograde left circumflex CTO PCI through an SVG: deflection technique, DK-Crush, and occlusion of the SVG.
Introduction:
Percutaneous coronary intervention (PCI) in native chronic total occlusion (CTO) in patients with prior CABG is challenging. Although vein grafts can be a good conduit to perform retrograde CTO PCI, they can sometimes be challenging to use with acute angulation of insertion. We present a case demonstrating the technique of OM2 CTO PCI through an SVG followed by occlusion of the SVG using AVP II occlusion device.
Clinical Case
57-year-old man with history of CABG (SVG-D1, SVG to OM2, SVG to RCA) with recurrent failure of SVG-OM2 and failed prior PCI attempts of native OM2 CTO. His echocardiogram showing global hypokinesis with LVEF 40%. Coronary angiogram showed CTO of OM2 with blunt proximal cap at the bifurcation of with OM1 covered with 2 layers of stents, long occlusion (40 mm) and distal cap at the insertion of SVG with acute angle. We decided to use a primary retrograde approach. A venture microcatheter was used to wire through the distal cap through the angulated SVG anastomosis but failed, we then used balloon deflection technique with a balloon inflated in the distal vessel and wiring was successful with a caravel and pilot 200. Penetration of the proximal cap failed with confianza pro 12 and pilot 200 so we used balloon inflation over the antegrade wire with a stiff Hornet 14 wire through the retrograde caravel microcatheter and that could penetrate the 2 layers of stent at the proximal cap. This was followed by externalization of R350 after confirmation of the wire position in the true lumen with IVUS. After balloon angioplasty, rewiring using a TwinPass was performed to avoid jailing the retrograde wire with stenting. Then we performed DK-Crush bifurcation stenting for OM1 and OM 2 with resulting TIMI III flow. To stop the competitive flow, we occluded the SVG using a 6 mm- 100 cm long AVP II occluder device. We shortened our guide to accommodate the 100-cm long AVP II, then we loaded it on a 6-Fr. Trapliner that was used to deliver the device to SVG. Angiographic results were excellent and confirmed with OCT.
Discussion
Our case demonstrates the complexity of CTO PCI in patients with prior CABG with the acute angulation at the SVG anastomosis when used as a collateral channel. We also demonstrate the difficulty of PCI with multiple prior stents at the origin of the native CTO vessel complicating reentry at the proximal cap. We used the balloon deflection technique, and escalating stiff wires to overcome challenges. We also demonstrate the feasibility of delivering AVP II occluder device through a 6-French Trapliner after manually shortening the guide catheter.