A 80’s year-old male on hemodialysis was admitted to our hospital because of chest pain while hemodialysis. 5 years prior to admission, He had coronary bypass surgery because of effort angina (left internal thoracic artery (LITA)-LAD, saphenous vein graft (SVG)-mid RCA, SVG-diagonal artery-obtuse marginal branch (OM)). At that time, the ostium of RCA was severe stenosis with calcification, not CTO lesion. His coronary risk factors included diabetes, hypertenison and dyslipidemia.

ECG showed pacemaker rhythm, so we didn’t estimate ST change. Cardiac echo showed that Ejection Fraction (EF) was 51.0%, and no asynergy. Coronary CT showed that distal RCA was severe stenosis with strong calcification though bypass graft was patent. 

RCA and Cx were occluded at the ostium. LM-LAD and mid LAD were severe stenosis with strong calcification. LITA-LAD, SVG-mid RCA and SVG-diagonal branch-OM were patent and blood flow was good. But severe stenosis with strong calcification was observed in distal RCA, the distal part of the bypass anastomosis.

The cause of chest pain was suspected to be due to a lesion in the distal part of the RCA. We devised two strategies for approaching this distal lesion. One approach was to open the CTO lesion at the ostium of the RCA and then open the distal lesion. The other approach was to approach the distal lesion through SVG. Because of the strong calcification of the distal lesion, it was considered necessary to deliver a rotational atherectomy device(RA), and there was concern that approaching from the ostium of the RCA could carry a risk of complications such as cerebral embolism during using RA due to the severe calcification at the CTO. Therefore, it was believed to be relatively safer to perform rota via SVG, and the procedure was carried out.Using a guide extension catheter, a RA was delivered to the distal lesion safely, and initially, ablation was performed with a 1.5 mm burr in the PL branch.  We crossed another wire to protec the PD branch and opened the PL branch by 2.5mm semicompliant ballon, Though we tried to pass the balloon to the PD branch,  the balloon did not pass, so ablation was performed with a 1.25 mm burr to the PD branch, which allowed successful passage of the balloon and expansion. Then, we implanted two DES, and the final angiography showed a good result.

This case was a unique one where a bypass was performed to the mid RCA. In cases where a bypass is anastomosed to the distal RCA, the approach employed in this case may not have been possible because of the long length of SVG and difference in vessel diameter between SVG and RCA. So it was considered a rare case that RA could be performed due to SVG being shorter than conventional. We could deliver RA to the distal lesion safely, using a guide extension catheter.We experienced a case using RA via the bypass graft.