This document describes a case of a 59-year-old male patient who presented with exertional angina and dyspnea. Coronary angiography revealed a mid-LAD CTO. Attempts at antegrade recanalization failed. Retrograde recanalization through septal collateral channels resulted in a septal perforation. Coils were implanted but the patient developed cardiac tamponade requiring pericardiocentesis. The perforation persisted and additional coils were implanted, but tamponade recurred requiring emergency cardiac surgery. The perforation was successfully treated with coils and surgery, and the patient was discharged after one week and had an uneventful recovery.

1. Alfredo R. Galassi MD, FESC, FACC, FSCAI
Director of Cardiac Catheterization and
Interventional Cardiology Unit
Department of Medical Sciences and Pediatrics
Division of Cardiology, Cannizzaro Hospital,
University of Catania, Italy
A Septal Perforation:
The Best Of The Worst

2. CASE SUMMARY
Clinical Presentation
Exertional angina (CCSC II)and dyspnea (NYHA II)
Patient: C-C, male, 59 yrs
Risk Factors
Hypertension Dyslipidemia
Coronary Angiography
Mid LAD CTO
Non-invasive Testing
2D Echo: Hypokinesia in anterior territory, EF 50%

3. Coronary Angiography
Target lesion: LAD

4. Antegrade Failed Attempt
Target lesion: LAD

5. Collaterals
Target lesion: LAD

6. Septal channels
Sion Asahi Intecc
Target lesion: LAD

7. Sion advancing through septal channels
Sion Asahi Intecc
Target lesion: LAD

8. Externalization
RG 3 Asahi Intec
Trapping balloon

9. Stent Implantation
2 DES
Cre8 3.0x31 mm; Cre8 2.75x31mm

10. Final Result (time: 2.0 pm o’clock)
Total procedural time = 18 min

11. After Corsair withdrawing

12. After Corsair withdrawing
Septal perforation

13. 7 min later …
Tachycardia and hypotension
Septal fenestration and pericadial effusion
TTE showed tamponade

14. Pericardiocentesis

15. Antegrade coil implantation

16. Retrograde coil implantation

17. Persistance of extravasation
Second retrograde coil implantation

18. Further retrograde coil implantation
in posterior descending artery

19. Absence of right ventricular perforation

20. Final Result
Stable hemodynamic status
HR 90 bpm; systolic pressure 110 mmHg
Thus, protamin was administered (35 mg)

21. 1 hour later… tachicardia and hypotension suddenly developed
Patiient was brought back to cath lab (time: 9.00 o’clock)
TTE showed
sudden increase
in pericardium
effusion and
tamponade
Angio revelaed again active bleeding
in pericardium from septal fenestration

22. Further antegrade quick coil implantation (no heparin infusion)
Because protamine administration and long-standing procedure
pericardiocentesis drainage became difficult
due to catheter clotting

23. Final Result (no active bleeding)
TTE confirmed clots in the pericardium with
signs of compression with unproductive drainage

24. Because of the incoming night and the
unproductive drainage it was decided to
transfer the patient for surgical
pericardium assessment

25. Cardio-thoracic chest opening was performed after 10 hrs
(time: 00.00 am o’clock)
No active bleeding in the pericardium was observed, finally stopped!
Surgical drainage of clots was performed

26. Outcome
Patient was discharged 1 week later
Two-month follow-up was uneventful
He is running daily working activity

27. Take Home Messages
- Septal channels represent reliable and relative safe collaterals to
achieve successful retrograde CTO revascularization
- Septal perforation is very often benign…… but not always;
“septal collateral fenestration” might be dangerous
- Coils are important tools in the armamentarium of CTO
operators (they achieve perforation closure with no significant
flow impairment in the main vessel)
- Emergency cardiac surgery should be considered in rare cases