Successful percutaneous coronary intervention for right coronary artery chronic total occlusion after Cabrol procedure a
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IMAGES IN CARDIOVASCULAR INTERVENTION
Successful percutaneous coronary intervention for right coronary artery chronic total occlusion after Cabrol procedure and the following coronary artery bypass grafting Tsuyoshi Honda1 · Shunichi Koide1 · Tomokazu Ikemoto1 · Ryusuke Tsunoda1 · Teruhiko Ito1 · Hiromi Yoshimura1 Received: 29 April 2020 / Accepted: 15 October 2020 © Japanese Association of Cardiovascular Intervention and Therapeutics 2020
A 53-year-old man was referred to our outpatient clinic for chest pain on exertion for a month. He underwent complete replacement of the ascending aorta and aortic valve with a composite graft with non-displaced coronary ostia for severe aortic regurgitation and ascending aortic aneurysm due to Marfan syndrome 25 years ago. Ten years later, he underwent replacement of the descending aorta with coronary artery bypass grafting (descending aorta to seg4PD) for descending aortic aneurysm and a severe stenosis of the right coronary artery (RCA) anastomosis. He underwent excise stress myocardial scintigraphy because of allergy for contrast mediums, and it showed inferior myocardial ischemia. Coronary angiography via right radial artery confirmed chronic total occlusion (CTO) of the RCA-Cabrol conduit (Fig. 1, white-arrow) and collaterals from the left anterior descending coronary artery and the left circumflex coronary artery (Fig. 1, left-panel). Considerating his past twice thoracic surgery for ascending aortic aneurysm and descending aortic aneurism because of Marfan syndrome, it was decided that the best revascularization was percutaneous coronary intervention (PCI). A 6-Fr Judkins-right4.0 guiding catheter (Launcher; Medtronic, USA) was cannulated into the Cabrol conduit. Then, we performed parallel wire technique using two 0.014-guidewires (ULTIMATEBros3, GaiaNext3; Asahi
intecc, Japan) under support of a microcatheter (CaravelMC; Asahi intecc, Japan). After the guidewire passed into the lesion, pre-dilatation using a 1.5 × 15 mm-balloon (Kamui; Asahi intecc, Japan) was performed. Although additional dilatation using a 3.0 × 15 mm-balloon (Tazuna; Terumo, Japan) was performed, a 3.5 × 12 mm drug-eluting stent (XienceSierra; Abbott, USA) could not advance into the lesion. After the stent was deployed at the RCA anastomosis by mother and child technique using a guide extension catheter (GuidezillaII; Boston Scientific, USA), post-dilatation using a 5.0 × 12 mm-balloon (NC-Kamui; Asahi intecc, Japan) was performed (Fig. 1, right-panel). The Cabrol technique includes replacement of the ascending aorta and aortic valve using composite graft [1]. It is important to recognize that the development of stenosis at the Cabrol graft-coronary anastomosis or diffuse stenosis secondary to retraction of the material is potentially catastrophic [2, 3]. Although we could not deeply engage the guiding catheter into the Cabrol graft, we succeeded this procedure by strengthening the back-up force using mother and child catheter technique. This is a first case report that reports successful transra
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