Where is it and How to do?

A 68-year-old lady from USA complained of sudden onset of severe chest pain at the airport. She had past history of hypertension, diabetes mellitus and CABG done twice for coronary artery disease. The details of CABG were not known. ECG showed transient ST elevation in the inferior leads and ventricular standstill. Urgent coronary angiography showed distal LM severe stenosis, ostial LAD and mid LCX CTO (Figure 1, Figure 2, Figure 3). RCA angiography revealed critical ostial disease and mid to distal segment diffuse disease (Figure 5, Figure 6). LIMA to LAD was patent (Figure 4). However, visualization SVG to LCX and RCA was not successful.  Careful examination of the cine images revealed markers in the descending aorta at the level of diaphragm. Non-selective injection with diagnostic JR4 catheter showed SVG to LCX and PDA at diaphragmatic level of descending aorta (Movie 1, Movie 2). High grade stenosis with possible high clot burden was observed in the SVG to PDA, the infarct related artery. 

The challenge of the PCI was high risk of distal embolization if the SVG to PDA was tackled. The segment of SVG distal to lesion was too short for distal protection device. On the other hand, PCI to the native RCA would be extremely difficult with poor guiding support due to ostial disease and diffuse distal disease. PCI to native RCA was finally decided. RCA was non-selectively engaged with 6Fr IMA catheter via right femoral approach and wiring of RCA was difficult (Movie 3). Finally, the RCA was successfully wired with Fielder FC wire. In order to improve the backup support, the wire was externalized to another guiding catheter (6Fr JR4) engaged into SVG to PDA (Movie 4) from right radial artery. After predilatation with non-compliant 2.0mm balloon, two very long DES (2.5/48mm and 2.75/38mm) were deployed from ostial to distal RCA without much difficulty, followed by post dilatation with non-compliance balloon. The final angiography result was satisfactory (Movie 5, Movie 6). 

Patient was asymptomatic after PCI and was discharged 3 days later.