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Case 193: Manual of CTO PCI - Compromise 1

A patient with 3 prior CABG surgeries presented with severe medically refractory angina in the setting of an LAD CTO. The CTO had ambiguous proximal cap at the takeoff of a large septal, diffusely diseased distal vessel filling via epicardial collaterals and a SVG-LAD that had occluded a year prior. Given proximal cap ambiguity a primary retrograde approach was attempted through the occluded SVG-LAD. The wire could be retrogradely into the mid LAD but then went outside the cardiac silhouette, likely into a prior LIMA-LAD graft. An antegrade attempt was made using BASE (balloon-assisted subintimal entry) but caused a perforation, requiring placement of 2 PK Papyrus stents. The SVG-LAD was successfully stented restoring flow to the LAD. Although recanalizing the native LAD would have been preferable, recanalizing the occluded SVG-LAD was a good compromise.