Importance of IVUS in the treatment with retrograde approach of a long in-stent chronic total occlusion of ostial right coronary artery: A case report

A 43 year-old male, with a long history of coronary artery disease, was electively admitted to our institution because of dyspnea for moderate physical efforts (NYHA 2) related to an in-stent chronic total occlusion of ostial RCA and with demonstration of a significant area of inducible myocardial ischemia at stress echocardiography. After a gentle attempt of antegrade approach, the in-stent CTO of ostial RCA was successfully reopened with a retrograde approach using a knuckle technique. After IVUS evaluation which showed that the course of the retrograde guidewire was mostly within the stent strut circumference with the exception of the ostial RCA where the guidewire past between the stent and the vessel wall, implantation of 4 drug-eluting stent was performed from mid to ostial RCA with a good final result. The hospital stay was uneventful. At 6 months clinical follow-up the patient was in good clinical condition. We discuss some aspects related to procedural technique, the importance of IVUS evaluation in the treatment of this patient.