Coronary Intervention in Chronic Total Occlusion in the Left Main Coronary Artery

An 83-year-old man who had undergone coronary aorta bypass graft surgery 25 years ago required treatment for new-onset worsening angina. Coronary computed tomography angiography (CCTA) showed total occlusion of the left main coronary artery (LM), proximal obtuse marginal (OM) branch and proximal right coronary artery (RCA), a tight, calcified lesion in the proximal left anterior descending artery (LAD) (Figure A) , patent bypasses of the left internal thoracic artery (LITA) to the LAD and the right internal thoracic artery (RITA) to the OM branch, and occlusion of the saphenous vein graft (SVG) from the aorta to the right coronary artery (RCA). Coronary angiography revealed total occlusion of the RCA and LM in their ostia (Figure B-a, b) , retrograde perfusion to the proximal LAD and left circumflex artery (LCX), distal RCA by LITA-LAD graft (Figure B-c; Video 1 ) , and limited perfusion of the OM branch by the RITA-OM branch graft (Figure B-d; Video 2 ) . The symptom derived from a large myocardial ischemia in the postero-lateral and inferior areas.