in behet 's disease , coronary ostial stenosis following a bentall procedure is rarely reported but can be fatal.1 ) among chronic total occlusion ( cto ) lesions , the ostial location is especially difficult to treat with percutaneous coronary intervention ( pci ) due to the inability to engage the guiding catheter into the coronary artery .
however a retrograde approach , has been recently introduced , which may increase the rate of success of pci.2 ) here we report a case of retrograde recanalization of a chronically occluded right coronary artery ( rca ) ostium after a repeated bentall procedure in a patient with behet 's disease .
a 41-year - old man with behet '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 ( fig .
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 ( fig .
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 ( fig .
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 .
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 ( fig .
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 ( fig .
3d ) and pulled out of the sheath placed in the right femoral artery using a multi - snare ( pfm medical , ca , usa ) ( fig .
the lesion was pre - dilated using a 2.020 mm lacrosse balloon ( goodman , nagoya , japan ) at 18 atmospheres . a 3.028 mm nobori stent ( terumo , tokyo , japan )
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 .
aneurysmal dilatations of the sinus of valsalva and ascending aorta are more frequent in patients with behet 's disease than in healthy subjects.3 ) the bentall procedure for aortic root and valve replacement with coronary reimplantation is considered the gold standard for treatment of combined valve and ascending aortic pathology,4 ) with coronary ostial stenosis following this procedure occurring in less than 2% of patients.5 ) this complication may be related to an imperfect suture technique , or to the direct instrumentation of the coronary ostium itself . in these cases ,
signs of ischemia typically present early on during hospitalization.6 ) in recent reports , delayed ostial coronary stenosis occurring within months of the operation might be due to inflammatory and/or proliferative responses of the coronary wall to tissue adhesives used during the operation.7)8 ) coronary artery stenosis in aortitis syndrome with the stenosis occurred two years after the operation has been reported.9 ) in our case , signs and symptoms of stenosis were observed 5 months after surgery .
thus , the time lapse between the procedure and the presentation of ostial occlusion implies a mechanism that is related to the tissue adhesion rather than the suture technique or behet 's disease itself .
our patient presented with acute myocardial infarction and underwent successful pci of the lmca ostium .
it was not possible to perform this procedure using an antegrade approach to the cto in the rca ostium .
it has been reported that successful revascularization of cto leads to significantly reduced mortality rates and long term risk of adverse cardiac events.10)11 ) retrograde cto recanalization has recently become an essential alternative to the classical antegrade approach . when performed by an experienced clinician , the retrograde technique has a high success rate with a low complication profile , despite frequent utilization in the most anatomically and clinically complex patients.2 ) in retrograde cto recanalization , analysis of all potential collateral channels is critical .
the epicardial collaterals are preferred less than septal collaterals , because rupture could lead to tamponade and procedural ischemia or infarction may occur.2 ) however , we used the epicardial collateral because no septal collaterals are suitable .
in addition , because the occlusion was located at the ostium of the coronary artery , there was no space to engage the antegrade guiding catheter .
in such situation , a pure retrograde wire crossing is the only way to transverse the occlusion .
the retrograde wire was able to advance to the false lumen and advancing more caused the dissection .
if available for antegrade approach , the use of intravascular ultrasound through the antegrade system may prevent the engagement to the false lumen.12 ) however , if not available for antegrade wiring , we have no choice but to advance the retrograde wire carefully by an experienced operator .
after crossing cto lesion , either pushing the retrograde guidewire into the guiding catheter or trapping it at the contralateral sheet may be used for wire externalization.13 ) through this retrograde approach , we were able to snare the 300 cm guidewire into the ascending aorta , and then ultimately pull it out of the proximal end of the femoral sheath . in summary , we propose that a retrograde approach for pci can be useful in the treatment of cto of the coronary ostium as a consequence of the bentall procedure in patients with behet 's disease .
 we describe a case of chronic total occlusion of the right coronary artery ostium 5 months after a repeated bentall procedure in a patient with behet 's disease . in this patient , 
 an antegrade approach to delivering the guidewire during percutaneous coronary intervention was not successful . 
 coronary angiography revealed the existence of collateral blood supply from the left coronary artery . using a retrograde approach , 
 a guidewire was successfully advanced from the distal left circumflex artery through the collateral vessel and into the posterolateral branch of the right coronary artery . after the guidewire crossed over the occluded right coronary artery ostium and was snared into the ascending aorta , antegrade access for balloon and stent delivery succeeded . 
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