Abstract
Background
In the absence of radiopaque graft markers, engaging unusual saphenous vein grafts can be challenging.
Methods
We describe a case in which a saphenous vein graft to the first obtuse marginal branch could not be located, in spite of performing aortic root angiography. The saphenous vein graft was wired retrogradely through the native left main and the wire was advanced into the aorta, serving as a marker of the abnormally low origin of the graft that was successfully engaged with a multipurpose catheter.
Results
The guidewire was successfully advanced retrogradely through the SVG into the aorta, allowing localization of the SVG ostium that was sewn in an unusually low location.
Conclusions
Retrograde SVG wiring is an advanced, “last resort” technique for identifying the ostium and cannulating unusual aortocoronary bypass grafts.
Engaging saphenous vein grafts (SVGs) can be challenging, especially when the coronary artery bypass graft surgical (CABG) report is not available and when bypass graft markers are not used during surgery. Usually multiple diagnostic catheters are used followed by aortic angiography that may demonstrate the origin and course of all bypass grafts. We describe a case in which after multiple unsuccessful engagement attempts and unrevealing aortic angiography, retrograde wiring of the SVG was performed, enabling SVG engagement.
1
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.
![](https://i0.wp.com/thoracickey.com/wp-content/uploads/2017/11/gr1-215.jpg?w=960)
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.
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