A patient with prior CABG presenting with exertional dyspnea and was found to have inferior ischemia. Coronary angiography showed patent SVG-distal RCA, but both the PDA and right posterolateral were occluded distal to the SVG distal anastomosis. He had an ostial RCA CTO and was referred for PCI of that lesion.
When CTO PCI was attempted the SVG had occluded distally but was successfully used to wire both the PDA and the right posterolateral. After balloon angioplasty flow was restored into both vessel. We tried to wire retrogradely to the RCA using a Sasuke and a SuperCross microcatheter without success. We knuckled an antegrade Gladius Mongo to the SVG anastomosis and using the antegrade knuckle as marker we were able to advance a Gaia Next 2 retrograde into the RCA. After guide extension reverse CART an R350 was externalized but the retrograde Turnpike LP microcatheter could not be removed. We created an antegrade knuckle with a Mongo wire and did multiple balloons inflations as well as IVL around the entrapped microcatheter. Afterwards the Turnpike LP was successfully removed after forceful retraction. Retrograde crossing was repeated with a Corsair Pro microcatheter followed by successful guide extension reverse CART. The PDA and right posterolateral were both wired using a Sasuke microcatheter, followed by removal of the retrograde equipment and stenting with an excellent final result.