A male patient aged 56, with a history of mechanical mitral valve replacement and CABG surgery a decade ago, presented at the hospital with complaints of left-sided chest discomfort. His symptoms included left-sided chest pain, dyspnea, sweating, atrial fibrillation, a heart rate of 37 beats per minute, and blood pressure of 110/60mmHg.

The ECG showed atrial fibrillation and a 3rd-degree AV block. The echocardiography revealed an EF of 63%, dyskinesia in the inferior wall, and normal mechanical heart valve function.The INR 3.16Creatinine: 78,4 umol/lUre: 7,2 mmol/lK+: 3,98 mmol/lTroponin Ths: 14,9 pg/mL

The results of the coronary angiography: - LM: Normal- LAD: Mild diffuse stenosis and occlusion at the end of LAD2, but it is fed by the LIMA bridge, which functions well. There is collateral circulation to the right coronary artery.- LCx: Old stent is still open but with a 50% stenosis after the stent.- RCA: Diffuse stenosis of 50-70% and total chronicocclusion of the PDA from the bifurcation site. The saphenous vein bridge is small and obstructed near the ostial due to thrombosis.
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We successfully aspirated the thrombus of the SV bypass using right femoral artery access (JR4.0, Runthrough 0.14, and Export™ catheter). This allowed us to restore the flow of the SV to the PDA. The patient was subsequently transferred to the Department of Cardiology for Lovenox, aspirin, and clopidogrel treatment. A repeat coronary angiography was done after three days due to persistent chest pain. The angiography showed that the SV bypass was blocked again. CTO intervention of the RCA was attempted using the right radial access, AL 0.756F, Runthrough 0.14. However, guiding into the RCA ostial was challenging, so a floating technique was employed with the help of a Finecross micro-catheter and a highly flexed second curve (over 90 degrees). Fortunately, driving through the lesion (with Runthrough) was not difficult. However, passing the ball over the lesion was challenging. Incremental balloons expanded the lesion with 10-16 atm pressure, including Pantera Pro 1.25x15mm, Pantera Pro 1.50x10mm, and PanteraPro 2.0x15mm. After measurement, stenting was done from the PDA to the RCA ostial using Cruz 2.5 x 48mm, Onyx 2.75 x 38mm, and Cruz 3.5 x 20mm with pressure 8-10 atm. Post-dilation was performed using Raiden 2.75x15mm, Pantera Leo 3.0 x 15mm, and Raiden 3.5 x 20mm balloons with pressure 14 to 24 atm. The flow after the intervention was satisfactory with TIMI3.
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Deferring stenting forpatients with acute coronary syndrome caused by degenerated saphenous veinocclusion is not recommended due to the significant risk of re-occlusion.Trying to revascularize the native vascular system may be challenging, but itmay result in good outcomes for the patient.