CT-Guided CTO-PCI Overcoming Bypass Surgery-Induced Native Coronary Artery Tenting

Keywords: chronic total occlusion, high-risk PCI, percutaneous coronary intervention

A 57-year-old male complaining of recurrent chest pain was admitted for recanalization of a chronic total occlusion (CTO) of the left anterior descending (LAD) artery. Ten years earlier, the patient underwent a coronary artery bypass graft (CABG), including a left internal mammary artery (LIMA)-LAD and right coronary artery (RCA) graft.

Angiographically, a proximal to distal long-occluded LAD with collateral filling from the left circumflex artery (LCX) (Figure 1A) was seen in addition to a severe LIMA-LAD anastomosis site stenosis. Preprocedural cardiac computed tomography (CT) showed significant tenting at the site of the LIMA anastomosis, along with heavy calcification in the mid part of the LAD (Figures 2A, 2B). Antegrade wire crossing of the mid calcified LAD (Gaia Third wire with Corsair-ProXS microcatheter [both Asahi Intecc]) was achieved. The wire was seen deflecting in a different pathway than the angiographically anticipated course of the vessel (Figure 1B). Therefore, the CT images were reanalyzed (Figure 2B). Surprisingly, the image combination showed that the wire was within the tented site of the LIMA-LAD anastomosis site and correctly positioned according to the vessel course (Figure 3). After further advancement of the wire, the recanalization was successfully completed (Figures 4A, 4B).

A CT-guided CTO-recanalization strategy can be supportive in long occluded segments and after CABG, which may affect the vessel course. However, more studies are needed to support this concept.

Affiliations and Disclosures

From the ¹Department of Cardiology, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany; ²DZHK (German Centre for Cardiovascular Research), partner site Berlin; ³Department of Cardiology, German Heart Center Munich, Munich, Germany; ⁴Berlin Institute of Health (BIH), Berlin, Deutschland; and ⁵Medizinische Klinik I (Cardiology and Intensive Care), Klinikum Darmstadt GmbH, Darmstadt, Germany.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted January 15, 2022.

Address for correspondence: Youssef S. Abdelwahed, MD, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin - Department of Cardiology, Hindenburgdamm 30, 12203, Berlin, Germany. Email: Youssef.abdelwahed@charite.de

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