A patient with prior CABG was referred for PCI of an ostial LAD CTO. The CTO had ambiguous proximal cap, length of approximately 80 mm, and diffusely diseased distal vessel that was filling via septal collaterals and an epicardial collateral from the PDA. He had an occluded SVG-LAD. Attempts to advance a guidewire retrograde into the septal failed and caused a non-flow limiting dissection. Antegrade wiring attempts of the PDA failed. A retrograde attempt through the occluded SVG-LAD was successful in crossing into the LAD. The patient subsequently had acute vessel closure of the PDA with chest pain and ST segment elevation. Antegrade wiring attempts of the PDA failed. A Suoh 03 wire was advanced retrogradely via the distal LAD epicardial collateral into the PDA and across the area of dissection into an antegrade Trapliner. An R350 wire could not be advanced due to tortuosity. A Gladius Mongo wire was used to “tip in” the retrograde Corsair, followed by advanced of a Caravel into the LAD and externalization of the R350 wire. A stent was successfully deployed across the dissection.
Retrograde crossing attempts of the LAD CTO failed and resulted in a perforation at the distal cap. Antegrade crossing attempts also failed but the perforation eventually sealed. The SVG-LAD was successfully stented restoring TIMI 3 flow to the LAD.
