The Path Less Travelled

  • The septal channels are the best conduit to utilize for retrograde approach
  • Very often we use it to cross from LAD to PDA and vice versa
  • There are times when I have used it to cross from LAD to a dominant LCx
  • This case shows a septal channel coming from mid LAD connecting to distal LAD

Baseline angiogram

  • This angiogram shows the CTO starting after the 2nd large septal
  • The distal entrance is small calibre

RAO cranial view of baseline

  • This view shows the septal collateral coming off the 2nd septal and joining the distal LAD

The initial antegrade approach

  • The initial approach was naturally antegrade as there appeared to be possible micro-channel
  • 135mm Corsair was utilised with Fielder Black wire
  • After a few repeated attempts, the wire remained in the sub-intimal space

Change of strategy was required

  • Deep injection into the Corsair was made to look for the septal collateral
  • It also shows that false lumen has been created and the antegrade micro-channel compressed

The Corsair entered the septal collateral

  • The septal collateral can be seen re-entering the distal LAD

Channel crossing

  • XT-R was used to gently cross the channel

Crossing completed

  • The XT-R re-entered the distal LAD and parked in a distal diagonal

Antegrade landmark

  • A Runthrough was parked in the proximal cap as landmark for retrograde crossing

Attempting to meet up

  • Although a Gaia 2nd was used, it was unable to penetrate the proximal cap

However, a Conquest Pro 12 (Confianza) was able to enter the proximal LAD

  • Since the Corsair used was only 135mm, it was not long enough to enter the guiding catheter
  • It was maneuvered across passed the CTO segment into the mid LAD and Conquest Pro changed out to RG3
  • The RG3 was then carefully driven into the guider and externalised
  • After initial pre-dilatation with 2.0 balloon, a Runthrough was passed down anterogradely and the retrograde system removed.
  • The LAD was stented in distal to proximal fashion

Final angiogram

  • This showed the adequately treated LAD
  • The septal channel is also more clearly seen