Case 237: Manual of CTO PCI - Retrograde via an ipsilateral septal collateral

A patient presented with exertional dyspnea and was found to have anterior ischemia and a mid LAD CTO. The LAD CTO had a blunt proximal cap with heavy calcification, short length, diseased distal vessel, and was filling via an epicardial collateral from an acute marginal and from a septal to septal collateral. An initial antegrade attempt failed due to inability to re-enter into the distal true lumen using the Stingray system. Repeat attempt 2 months later was done via the ipsilateral septal to septal collateral. Crossing attempts of the collateral with a Sion black wire resulted in perforation but repeat attempts with a Suoh 03 wire resulted in successful guidewire crossing. After reverse CART the retrograde wire was externalized, followed by antegrade wiring of the LAD using a Sasuke dual lumen microcatheter. After removing the retrograde wire the LAD was stented with an excellent final result.