PERCUTANEOUS CORONARY INTERVENTIONS

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Unnecessary saphenous graft results in LIMA failure after CABG, the worst comes when the saphen also failed!

Operators:Assoc. Prof. Mutlu Vural

Medical Sciences University Bağcılar Training and Research Hospital

Introduction

A 70 year-old patient underwent bypass surgery 11 years ago (Ao-PDA, Ao-OM, Ao-D2, LIMA-LAD). He has complained angina for last 2 years. He defines severe effort angina even with walking <10 meters. He also has COPD, redo CABG has a high risk. His ECG showed previous anterior infarction. On angiogram, there was a CTO lesion in the RCA  (Video 1). The LCX had a seperate ostium  (Video 2). The OM had a significant stenosis, but Ao-OM was patent and also supplied PDA  (Video 3). The LAD was single open artery, which had diffuse disease  (Video 4). Ao-D2 saphen was only visible retrogradely. LIMA was atrophic probably due to unnecesary A0-D2 saphen  (Video 5).

Case presentation

7Fr JL 4.0 guide catheter was taken. Wiring to distal LAD was impossible  (Video 6). We delivered the first guidewire to occluded saphenous graft (impossible to cross the lesion retrogradely). Advanving a second wire (parallel wiring) is not possible. Then we dilated the lesion with a low profile balloon and tried parallel wiring again, but still unsuccessful. We dilated more to advance double lumen microcatheter (distal perfusion is essential after delivering the microcatheter). Wiring attempts at different levels and positions via double lumen microcatheter failed at all (Video 7). Minor dissection leaded narrowing of stenosis in the distal LAD, probably due to compression by a hemathoma. Because his creatinin level was 1.3, I then have decided to put a stent from mid LAD to D2 and then proximal LAD (Video 8). Reverse wiring would have been worked, maybe next time I will try it. Finally, distal LAD flow was TIMI-3  (Video 9). I decided to perform re-intervention as well as evaluating requirement of postdilatation (reflow after CABG might result in positive remodelling which result in underexpansion of the stent. Unfortunately intracoronary imaging is not possible) one month later.

Take home messages

  1. Avoid unnecessary saphenous graft during CABG which results in LIMA failure.
  2. It’s not worth risking LIMA by anastomosng saphenous vein to the diagonal artery.
  3. LIMA anastomosis may result in tortuosity in the native vessel, which can cause difficulty during wiring attempts

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