Retrograde approach via left internal mammary artery using a 5 Fr guiding catheter

Area of Science:

• Cardiovascular Medicine
• Interventional Cardiology
• Vascular Surgery

Background:

• Coronary artery bypass grafting (CABG) is a common procedure for coronary artery disease.
• Saphenous vein grafts (SVGs) are frequently used but prone to degeneration and occlusion.
• Non-ST elevation myocardial infarction (NSTEMI) with acute heart failure presents complex management challenges, especially with prior CABG.

Observation:

• A 64-year-old female with prior CABG presented with NSTEMI and acute heart failure.
• The SVG-RCA was identified as the culprit lesion due to angiographic thrombus.
• Direct percutaneous coronary intervention (PCI) of the SVG-RCA posed a high risk of distal embolization and slow-flow phenomenon.

Findings:

• A successful primary PCI was achieved using a retrograde approach to the native right coronary artery (RCA).
• The retrograde access utilized a septal channel originating from the left anterior descending artery, bypassed by a left internal mammary artery (LIMA) graft.
• A microcatheter and guidewire were navigated through the LIMA and septal collateral to reach the distal native RCA.

Implications:

• This case demonstrates the feasibility and success of a retrograde PCI approach for complex SVG interventions.
• The technique offers a viable alternative when direct antegrade intervention carries significant embolic risk.
• This strategy may improve outcomes for patients with degenerated vein grafts presenting with acute coronary syndromes.