Retrograde recanalization of native right coronary artery chronic total occlusion (CTO) through left coronary artery CTO after bypass graft failure

Rationale: With the development and standardization of modern chronic total occlusions (CTOs) recanalization technique, percutaneous coronary intervention has become a promising treatment alternative to surgery after bypass graft failure. Treatment of a native coronary CTO lesion is preferable to treatment of a saphenous vein graft (SVG) CTO supplying the same territory; however, technical expertise is required. Patient concerns: This is a 69-year-old male with prior history of coronary artery bypass grafting presented with severe dyspnea at mild exertion (NYHA III) of 2 months duration. Diagnosis: The patient was diagnosed as heart failure caused by ischemia after SVG failure (SVG to right coronary artery) according to electrocardiogram, plasma N-terminal pro-B-type natriuretic peptide levels, and coronary angiogram. Interventions: We recanalized native right coronary artery CTO by retrograde approach using septal collaterals by surfing technique after recanalization of totally occluded left coronary artery. Outcomes: Dyspnea was relieved at discharge. At 6-month follow-up, the patient had no recurrence of dyspnea. Lessons: In case of SVG failure, percutaneous coronary intervention of native vessel should be considered as a treatment option. Retrograde approach through native vessel is safe but has requirements for operators’ volume, skill, and experience.