Long RCA Occlusion: Application of the Various Techniques for Successful Treatment
Emmanouil S. Brilakis, MD, PhD
Associate Professor of Medicine
University of Texas Southwestern Medical Center
VA North Texas Healthcare System
About the Video:
This is a case of a 65-year-old man with prior coronary artery bypass graft surgery (17 years prior) who presented with exertional angina. A dobutamine stress echocardiography showed inferior ischemia. Diagnostic angiography demonstrated that there were occlusions of the proximal right coronary artery and the mid-left anterior descending artery. All bypass grafts were occluded except for a left internal mammary artery graft to the left anterior descending artery.
We decided to attempt intervention of the right coronary artery occlusion. Due to lesion complexity, a primary retrograde approach was used for lesion crossing. The first septal collateral branch was successfully crossed with a Sion guidewire over a FineCross microcatheter.
Retrograde engagement of the lesion initially failed, as did antegrade crossing attempts. The retrograde guidewire was exchanged for a Pilot 200 guidewire that formed a knuckle that crossed the lesion subintimally until the proximal right coronary artery.
Re-entry into the proximal true lumen was achieved using the reverse-CART technique, followed by wire-snaring and externalization. After stent implantation, TIMI-3 antegrade flow was restored in the right coronary artery, resulting in resolution of the patient’s exertional angina.