Septal Collaterals in a Chronic Total Occlusion

Percutaneous coronary intervention of a chronic total occlusion (CTO) should be considered in patients with angina or with documented ischemia. We present a patient with angina and stress echocardiography positive for ischemia in the anterior wall. The coronary angiography revealed a CTO in the left anterior descending artery, and a percutaneous approach was decided. The antegrade dissection reentry was unsuccessful. Retrogradely, through the ipsilateral septal collaterals, a SUOH wire was successfully advanced distally to the CTO. Externalization of the RG3 was successful, and the antegrade microcatheter was advanced inside the distal septal. Successful percutaneous coronary intervention of the left anterior descending artery was performed. Ping pong technique was not used, making the procedure challenging for equipment delivery. One injection, one solution technique can be applied in selected cases with ipsilateral septal collaterals. Careful evaluation of the coronary anatomy before the procedure is mandatory.