A Retrograde Approach to Coronary Ostial Stenosis after a Bentall Procedure in a Patient with Behçet's Disease
A 41-year-old man with Behçet's disease was referred to our outpatient clinic for treatment of CTO of the RCA ostium. He did not have any risk factors such as hypertension, diabetes, hyperlipidemia, and smoking. He had undergone a Bentall procedure for severe aortic regurgitation 10 years ago, and required reoperation on the aortic root replacement with Prima Plus 23 mm (Edwards Lifesciences, Irvine, CA, USA) and an ascending aortic graft insertion with Intergard 24 mm (Maquet, Wayne, NJ, USA) due to infective endocarditis 7 months prior. Two months earlier, he experienced rapidly worsening exertional angina and was evaluated at another hospital. Emergent coronary angiography showed a significant tubular lesion of the left main coronary artery (LMCA) ostium () and total occlusion of the RCA ostium (). Stent implantation in the LMCA was successfully performed, but catheter engagement into the RCA failed due to CTO of the RCA ostium. On admission, electrocardiography revealed abnormal Q waves over the inferior leads (), but cardiac magnetic resonance imaging showed no evidence of delayed enhancement. Echocardiography showed normal left ventricle systolic function and aortic valve function. Coronary angiography showed a patent LMCA stent and no disease in the left sided vasculature; however, the RCA ostium was totally occluded and collateral flow (grade 3) was supplied by the left coronary artery (). We first attempted to use a 6 Fr JR 4 guiding catheter (Cordis, Miami, FL, USA) for an antegrade approach, but were unable to penetrate into the RCA ostium. Subsequently, a 5 Fr XB 3.5 guiding catheter (Cordis, Miami, FL, USA) was used in a retrograde approach via the right radial artery. We chose the left circumflex artery (LCX) for the retrograde approach. A superselective tip injection of contrast using a Finecross™ microcatheter (Terumo, Tokyo, Japan) was performed, and a channel from the LCX to the posterolateral branch of the RCA was confirmed. A Runthrough™ NS (Terumo, Tokyo, Japan) with a microcatheter was retrogradely advanced into the distal RCA, and further advanced into the distal end of the occlusion () before penetrating the CTO lesion (). We then exchanged the Runthrough™ NS guidewire for a Fielder-FC™ 300 cm guidewire (Asahi Intecc, Aichi, Japan), which was subsequently snared into the ascending aorta () and pulled out of the sheath placed in the right femoral artery using a Multi-Snare® (PFM medical, CA, USA) (). The lesion was pre-dilated using a 2.0×20 mm Lacrosse balloon (Goodman, Nagoya, Japan) at 18 atmospheres. A 3.0×28 mm Nobori® stent (Terumo, Tokyo, Japan) was then placed successfully in the CTO lesion at 16 atmospheres. Final angiographic findings showed no residual stenosis or complications (). The medications of the previous hospital were maintained including colchicine 0.6 mg qd, azathioprine 50 mg qd, aspirin 100 mg qd, clopidogrel 75 mg qd, ramipril 5 mg qd, bisoprolol 5 mg qd, and atorvastatin 80 mg qd. He was referred back to the previous hospital.