Images in cardiovascular medicine. Interventricular septal hematoma and ventricular septal defect after retrograde intervention for a chronic total occlusion of a left anterior descending coronary artery.

A 73-year-old man with unstable angina was found to have a severely calcified chronic total occlusion (CTO) of the mid left anterior descending coronary artery (LAD). Diagnostic coronary angiography confirmed the CTO to be complex, with a “flush” occlusion occurring in a segment associated with proximal septal and diagonal branches. Retrograde filling of the distal LAD occurred via 2 large septal perforators from the right coronary artery (RCA). Cardiac magnetic resonance imaging demonstrated preserved left ventricular systolic function with viability. After discussion, the patient opted for percutaneous coronary intervention. Intervention was performed by 2 high-volume CTO operators with extensive experience of retrograde CTO percutaneous coronary intervention. An initial antegrade approach failed to negotiate the calcific CTO lesion (Figure 1A). A subsequent attempt was made to treat the CTO via a retrograde approach. Figure 1B demonstrates retrograde filling of the LAD. It was possible to advance a floppy hydrophilic guidewire (Whisper LS, Abbott Vascular, Ill) via the septal perforators from the posterior descending branch of the RCA to the LAD