Crossing an Angulated SVG–RCA Anastomosis Using Distal Anchoring and Guide Extension: A Bailout Strategy in STEMI

A 63-year-old male with a history of 2-vessel CABG (LIMA-LAD, SVG-RCA) presented with several hours of radiating chest pain. Electrocardiogram was significant for an inferior ST-elevation myocardial infarction. In the cardiac catheterization laboratory, the culprit lesion was identified as the right posterior descending artery. However, despite multiple attempts using an extra support guiding catheter, several drug-eluting stents and a drug-coated balloon were unable to advance beyond the anastomosis due to the acute takeoff of the RCA from the SVG. In response, a unique bailout approach utilizing a guide extension catheter (GEC) with distal balloon anchoring to facilitate deep GEC intubation across the acutely angulated graft anastomosis was employed; this technique facilitated the successful delivery and deployment of a drug-eluting stent. Potential complications associated with GEC and balloon anchoring include coronary artery dissection, challenges in stent advancement, air embolism, luminal obstruction, and vessel barotrauma. LEARNING OBJECTIVE: In STEMI with severely angulated SVG-native coronary anastomosis, distal balloon anchoring can enable deep guide extension catheter intubation across the anastomosis, facilitating device delivery when conventional strategies fail.