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Case 220: Manual of CTO PCI - Don't stent across the SVG distal anastomosis!

A patient was referred for PCI of a native right coronary artery CTO due to recurrent failure of a saphenous vein graft to the PDA. A stent had previously been placed across the SVG distal anastomosis with the PDA. The side-BASE technique was used to advance a knuckled Gladius Mongo wire extraplaque, while avoiding an acute marginal branch located at the distal cap. Despite using multiple penetrating guidewires and various microcatheters, including the Venture, a guidewire could not be advanced through the previously placed stents at the SVG distal anastomosis even after doing intravascular lithotripsy in the native vessel at the anastomosis that had under-expansion. Using the Stingray balloon and the “stick and drive” technique a Gaia Next 3 was advanced into the distal true lumen in the right posterolateral. IVUS showed that re-entry had actually been achieved through the previously placed stent at the SVG anastomosis. Stents were placed in the RCA all the way to the right posterolateral, resulting in occlusion of the PDA. A wire was advanced through the SVG-PDA into the right posterolateral, followed by kissing balloon inflation that restored antegrade TIMI 3 into the PDA, achieving a nice final result.