Right Coronary Artery Chronic Total Occlusion After Bypass Grafting Successfully Treated Using Reverse Controlled Antegrade and Retrograde Subintimal Tracking (CART) Technique via the Gastroepiploic Artery: A Case Report

BACKGROUND Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) is a well-established treatment option, improving health status and angina in selected patients with angina and/or a large area of documented ischemia and suitable anatomy. It has been used in patients with a history of coronary artery bypass grafting (CABG) but remains controversial in unusual bypass constructions. This report is of a 63-year-old man with angina due to right coronary CTO, 6 years following CABG, successfully treated using the reverse controlled antegrade and retrograde subintimal tracking technique (reverse CART technique) via the gastroepiploic (GE) artery. CASE REPORT A 63-year-old man with a history of extensive coronary artery disease, including a CTO of the right coronary artery (RCA), previously treated with a right GE artery bypass graft, presented with unacceptable angina despite optimal medical treatment. A vascular CT scan suggested severe stenosis at the level of the anastomosis between the GE artery graft and the posterior descending (PD) artery. A PCI of the native RCA CTO was successfully performed using the GE artery bypass graft as a retrograde conduit, with good angiographical and clinical outcomes. CONCLUSIONS PCI of a CTO via the GE artery has been described only occasionally before, and remains a rare treatment. This report shows that retrograde coronary artery recanalization of CTO using the reverse CART technique, via the GE artery bypass graft, was safe and effective in this case, and that it can and should be considered in selected patients.