Retrograde percutaneous coronary intervention via critically degenerated saphenous vein grafts for chronic total occlusion in native coronary arteries

We report the case of a 78-year-old woman with saphenous vein graft (SVG) disease and chronic total occlusion (CTO) in three native coronary arteries [left anterior descending artery (LAD), left circumflex artery, and the right coronary artery], who was successfully treated by percutaneous coronary intervention (PCI) using the retrograde approach via the critically degenerated SVGs. The patient, a 78-yearold woman, presented with sudden chest pain and dyspnea. She had previously undergone coronary artery bypass surgery using SVGs for the three vessels and percutaneous coronary intervention with sirolimus-eluting stent placement in the posterolateral branch 13 and 3 years ago, respectively. Electrocardiography revealed ST-segment elevation in leads V1-4, whereas emergent coronary angiography revealed total occlusion in her native coronary arteries. Primary PCI was scheduled. A channel dilator was advanced very smoothly and safely into the distal site of the CTO lesion in the LAD, which showed complete occlusion in the proximal region, via an SVG that was temporally occluded four days earlier. A reverse controlled antegrade and retrograde tracking technique was used to successfully perform percutaneous recanalization. Subsequently, the other two native CTO lesions protected by critically degenerated SVGs were treated with retrograde intervention via the SVGs. The retrograde approach via critically degenerated SVGs is safe, reliable, and fast. If an SVG bypassing the native CTO lesion is critically degenerated, percutaneous coronary intervention should be performed via the SVG.