SHA24/089001

Osama Elkhateeb, MD, FRCPC, FACC Director of Cardiac Center King Abdullah Medical City in Holy Capital Makkah, Saudi Arabia

Case Presentation

Angiography • LAD and LCx: minor wall irregularities • RCA: Occluded proximally with collaterals from LAD. • Good distal vessel.

Approach

•RAO Cranial view: shows good septals supplying cllaterals to the RCA

•RAO view: shows good septals supplying cllaterals to the RCA

•Fielder FC wire negotiated through the septals and reached the distal RCA. (surfing technique) •Corsair is following the wire through the septals

Corsair already crossed septals

•Retrograde wire not advancing despite switching to confianza 12 wire. •So antegrade wire pilot-50 is advanced

•Antegrade wire is subintimal •Retrograde wire is intimal distally but ? subintimal proximally

•Both wires meet in different subintimal planes

Confirm position in different view

Confirm position in different view

Reverse CART: 2.0 X12 Balloon

Retrograde wire crossed to aorta

•Retrograde wire into the antegrade guide •‘then externalization of the retrograde wire using pilot 200 (300 cm) wire

•Predilatation with 2.5 x 20 balloon •Notice the Corsair Position ???!!!

•Stenting Distally to proximally

•Post stenting •Good results but notice perforation distally

•Distal perforation of the PD to heart Chamber, ?

RV •Prolonged balloon inflation distally, but did not change

Another view

Another view

 Patient hemodynamicly stable.  Stat Echo: no pericardial effusion  Echo: There was a flow between the Septum and RV but no VSD  2 months follow up, patient asymptomatic.  ECHO Follow up: showed disappearance of the flow

Retrograde Channel Perforation  Prevention  Careful angiographic assessment  Check difficulty of micro-catheter cross in channel  Watch your Corsair Position  Don’t leave the wire without the corsair across the septals.

 Treatment  Septal channel: leaving in almost all cases  Epicardial channel: coiling

•Predilatation with 2.5 x 20 balloon •Notice the Corsair Position ???!!!