Doctor & Patient Education Cardiac Specialist Centre
13. 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

Know Your Cardiologists

I feel breathless when walking.

I feel a tightness over my chest.

Do I need to take my medicine for my blood pressure?

Do I need to take my medicine for my cholesterol?

Do I really need stents for my artery?

Do I really need to have a bypass operation?

When should I go for health screening?

I have heart problem, can I take Viagra?

I have heart problem, should I exercise?

Heart Disease
Learn about your heart Conditions

You may need an ultra sound scan of your heart to assess its function.

You may need a treadmill stress test.

You may need closer monitoring.

You may need a more thorough risk assessment and life style change.

You may only need to take your medicine.

You may get away with just stenting.

This generally should start at 40 years old.

Yes, but there are certain strict conditions to fulfill.

Yes, but you will need to find out the appropriate intensity.