Case 169: Manual of CTO PCI - Complicated Rx of a SVG aneurysm

A patient was found to have a large (and growing in size) saphenous vein graft aneurysm 25 years after CABG. The aneurysm was located in the mid segment of the SVG-RCA and the native RCA was occluded proximally. He was referred for PCI of the native RCA CTO followed by occlusion of the SVG-RCA. The SVG was crossed easily with a guidewire and a 6 French guide extension was advanced distally visualizing the distal RCA. Initial retrograde crossing attempts failed (a guidewire could not be advanced retrogradely to the RCA). Antegrade crossing attempts using a knuckled guidewire failed to advanced distally. Repeat retrograde attempts were made: using a Sasuke microcatheter a Sion black guidewire was advanced to the distal RCA, followed by advancement of a Turnpike LP microcatheter. After multiple attempts the CTO was successfully crossed using the reverse CART technique. During stenting a mid RCA large vessel perforation was observed. An antegrade balloon was inflated achieving hemostasis but during subsequent attempts to retrieve it the balloon tip fractured and remained within the vessel. A retrograde balloon was inserted in the perforated mid RCA and inflated achieving hemostasis, followed by delivery and deployment of a PK Papyrus covered stent. The balloon fragment was retrieved using a guide catheter extension, followed by antegrade deployment of another covered stent sealing the perforation. The aneurysmal SVG was occluded with a 10 mm Amplatzer vascular plug. The patient required chest tube insertion the following day and subsequently recovered.

[@fatherabdul]

Manos, You have the hands of God working with you. Merry Xmas . Abdul Keylani

[@shangz0216]

Thanks for the educative case presentation.

[@ahmettemiz2528]

thank you for all of educative videos. Every video you share includes invaluable knowledge and practise. regarding this case I have a question. Because the aneurysm continues to have flow from distal RCA doesn't it carry a risk of growing and eventually rupturing?

[@fgj427]

Excellent case Prof. Manos, I have some questions
1. Was there any possibility for more distal coiling of SVG graft, let’s say near the RCA anastomosis ?
2. How do you decide and size for the SVG closure device, coils or amplatzer ?
3. What’s the extreme size you’d recommend for a balloon in a reverse CART ?
Many thanks for the excellent cases and books and Merry Christmas

[@manosbrilakis]

Great points:
1. Yes, that could have done, but then flow might continue into the aneurysm cavity
2. For Amplatzer vascular plugs, I usually use 50% oversizing - for example 6 mm plug with a 4 mm vessel
3. The size of the reverse CART balloon depends on the size of the vessel and the subintimal space - there is "one size fits all". IVUS can be very useful to determine the vessel size.

[@fgj427]

@@manosbrilakis Thanks for the reply Prof. Brilakis, I’m just an interested novice in CTO PCI, really learnt a lot from you.
Another point, if we close the SVG at the anastomosis, how would blood flow to the aneurysm ?

[@Stentordoc]

Rather than treating the CTO, did you consider just using covered stents in the SVG, similar to how a AAA is excluded with a covered stent graft? I have done this for smaller coronary aneurysms. It looked like the proximal and distal landing zone diameters in the SVG were about 4-5mm by IVUS; I’d have to check if we have covered stents that big.

[@manosbrilakis]

Excellent point!
This is definitely an option and I have done it for other SVG aneurysms. The advantage is that the procedure is simpler to perform. The disadvantages is achieving adequate sealing, off-label use of PK Papyrus requiring IRB approval (unless you use a peripheral covered stent), and the risk of SVG disease progression.

[@fgj427]

Can we use the graft stent in the RCA it self to seal the connection to the graft ?

[@ajfarber]

Do you think hemothorax was related to pci?

[@manosbrilakis]

Yes!