An alternative treatment strategy for large vessel coronary perforations

The standard treatment for large vessel coronary perforations is implantation of a covered stent. Antegrade attempts for crossing a right coronary artery chronic total occlusion resulted in guidewire and microcatheter exit with pericardial bleeding. A balloon was inflated proximal to the perforation site to achieve temporary hemostasis. Retrograde crossing of the chronic total occlusion was achieved through an epicardial collateral using the reverse controlled antegrade and retrograde tracking technique. Stent implantation resulted in hemostasis, likely due to creation of a subintimal flap that sealed the perforation site. If technically feasible, subintimal recanalization can be an alternative treatment strategy for coronary perforations occurring during chronic total occlusion percutaneous coronary intervention.