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Case

A 65-year-old woman, who had CABG 10 years prior, presented with exertional dyspnea and a nuclear stress test showing lateral wall ischemia. Coronary angiography revealed severely disease distal left main, left anterior descending and circumflex arteries ( Fig. 1 A ) and occlusion of the mid right coronary artery. The first diagonal and right posterior descending artery was filling via SVGs ( Fig. 1 B and 1 C) and the left anterior descending artery was filling via a normal left internal mammary artery graft ( Fig. 1 D). Although competitive flow could be seen in a large first obtuse marginal branch ( Fig. 1 A), no graft could be found to supply this territory, in spite of using multiple catheters (JR4, 3DRC, LCB, AL1, Multipurpose, Jackie). Ascending aortography also did not reveal the origin and course of the missing graft ( Fig. 1 E). A surgical report was not available.

Coronary angiography demonstrating severe left main and diffuse left anterior and circumflex coronary artery disease with competitive flow in the first obtuse marginal branch (arrow, panel A). Selective angiography of a saphenous vein graft to a diagonal branch demonstrating a severe proximal lesion (arrow, panel B). Selective angiography of a saphenous vein graft to the right posterior descending artery (panel C) and of the left internal mammary graft to the left anterior descending artery (panel D) demonstrating no significant graft obstruction. Ascending aortography did not demonstrate the course of the saphenous vein graft to the first obtuse marginal branch (panel E). A coronary guidewire was advanced retrogradely into the saphenous vein graft to the first obtuse marginal branch (arrows, panel F) until it exited into the aorta (arrow, panel G), enabling graft engagement with a multipurpose catheter (arrow, panel G) inserted via contralateral femoral arterial access. Selective angiography of the saphenous vein graft to the first obtuse marginal branch demonstrating no significant luminal obstruction (panel H).

Dual femoral arterial access was obtained and the SVG to OM was wired retrogradely using a 3.5 XB guide catheter and a Whisper wire (Abbott Vascular, Santa Clara, California) through a Renegade microcatheter (Boston Scientific, Natick, Massachusetts) ( Fig. 1 F). The Whisper guidewire was advanced retrogradely through the SVG into the aorta, allowing localization of the SVG ostium that had an unusually low origin, immediately above the right coronary cusp. The SVG to the obtuse marginal branch was subsequently easily engaged with a multipurpose catheter and selective angiography did not demonstrate any significant lesion ( Fig. 1 H). The patient underwent successful stenting of an ostial lesion of the SVG to diagonal (panel 1B) with an excellent final angiographic result. The patient had complete angina resolution.