Retrograde Guidewire Trapping Technique for Total Right Coronary Occlusion with Unusual Ostial Origin

Case Report A 64-year-old man was admitted to our institution on November 7, 2011, complaining of chest pain upon exertion for the previous year. Prior history: hypertension for more than 10 years, highest blood pressure 215/115 mmHg, 30-year history of smoking, 10 cigarettes per day. ECG on admission showed: increased II, III, AVF leads, small electrocardiogram (EKG)’s Q waves (Q), EKG’s ST segment (ST) depression 0.05 mv, T wave inversion. Admission diagnosis: 1) coronary old inferior myocardial infarction, unstable angina, New York Heart Association (NYHA) chronic heart failure (CHF) class II. 2) Hypertension class III. Cardiac catheterization, via the right radial artery: Left Main no stenosis, middle Left Anterior Descending (LAD) is 50% and distal 60% stenosis. Proximal Left Circumflex (LCx) showed 50-60 % stenosis, middle diffuse stenosis 90%. Two collateral circulation pathways were also observed: LAD to septal branch to Right Coronary Artery (RCA) with formation of limited myocardial collateral circulation; however, the LCx to left atrial branch to RCA epicardial collateral circulation showed good collateral blood supply (Figure 1 A). Selective right coronary angiography did not find the opening for the RCA, non-selective angiography suggested that the opening of the RCA could be totally occluded or the origin was abnormal (B). Because the patient refused coronary artery bypass surgery, it was decided to use a retrograde guidewire trapping technique using a “Memory-Snare” device by Shanghai Shape Memory Alloy Co. Ltd., China. A 7F EBU 3.75 guide catheter was placed via the right femoral artery, to the left coronary ostium. Super-selective angiography using a “Finecross” micro-catheter was performed. The septal branch did not show good collateral circulation to the distal right coronary (C). The Finecross was then sent into the circumflex artery to the left atrial branch over a Fielder Fc guidewire. Tip injection showed there was good collateral flow to the RCA (D, E). The Finecross was exchanged for an Abbot Vascular Pilot 150 catheter and passed by the retrograde route through the proximal right coronary occlusion, following an anomalous route into the ascending aorta, where it could be captured by the Memory-Snare device. Subsequently, a JR 4.0 guiding catheter was placed via the right radial artery and sent to the right coronary sinus; the angiography showed anomalous origin of right coronary openings (F). The same JR 4.0 guiding catheter was then used to deploy the Memory Snare device. The Pilot 150 guidewire was then connected to an extension wire. The Memory Snare device was used to capture the retrograde Pilot 150 into the JR 4.0 guiding catheter (Figure 2, Panel G), and pull it out of the body though the radial artery (Figure 2, Panel H). Antegrade along the Pilot 150 guidewire, a PTCA 2.0 × 20 mm balloon catheter was inserted and used to enlarge the stenosis of the RCA (Figure 2, Panel I); angiography identified the abnormal RCA opening on the left coronary sinus. Also visible was the stenosis throughout the length of the RCA (Figure 2, Panel J). Implantation of Partner rapamycin-eluting stents in the distal, middle and proximal right coronary, respectively (Figure 2, Panel K); postoperative angiography showed good RCA imaging with Thrombolysis In Myocardial Infarction (TIMI) 3 flow grade, without residual stenosis in the stents (Figure 2, Panel L).