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Case 7: Severely Angulated Vein Graft PCI

Case Presentation

  • A 74-year-old male presented with angina like chest pain, mainly exertional but occasionally at rest, and relieved with SL NTG or NTG patch.
  • PMH: HTN, HLD, DM, prior non-Q wave MI in 2005, PAD s/p PTAs, former smoker, obesity.
  • Cardiac History: CAD s/p CABG x 2 vessel (LIMA to LAD, SVG to OM1) in 1994, and s/p multiple PCIs.
  • Medications: ASA 81mg, Clopidogrel 75mg, Amlodipine 10mg, Valsartan 160mg, Metoprolol XL 50mg, Rosuvastatin 40mg, Metformin 1G.

Diagnostic coronary angiogram

Subtotal occlusion of left main, total occlusion of LAD, subtotal occlusion of LCx.
Mild disease in RCA.


Patent LIMA to LAD

90-95% stenosis located in SVG graft after severely angulated band (U shaped bend)

PCI Strategy

  • With the presence of severely angulated bend prior the lesion, we anticipated that the device delivery will be difficult
  • 6F AL guide with upfront use of guide extension catheter
  • Buddy wire technique with a stiffer wire and workhorse wire

With the support of AL1 6F guide catheter and Guidezilla, Runthrough was used to negotiate the lesion.

PTCA with compliance balloon 2/12 performed. (14 atm)

  • Since the lesion was not adequately expanded, we had used cutting balloon angioplasty (i.e. Wolverine 2.5/6mm) at 8 atm.


  • With these challenging anatomy, we used buddy wire technique (Grand Slam and Runthrough) to deliver the equipment.
  • Initial attempt was not successful to deliver the stent on Runthrough wire.
  • Then, we delivered the stent on Grand Slam wire and deployed with a good result.

Stent Position

Final Angiogram

Learning Points

  • In a tortuous or severely angulated vein graft intervention, use of adequate guide-catheter support, a guide extension catheter, and strong support coronary guidewire are vital to have a procedural success.
  • Buddy wire technique is useful in difficult circumstances with delivering the device/stents. (i.e. Grand Slam and Runthrough)
  • Coronary stent can be delivered either on soft wire or extra-support wire (Grand Slam). We delivered the stent successfully via Grand Slam in this case.

Left Main DK Crush Video ID