Thrombotic donor vessel injury. A patient status post failed antegrade revascularization of a mid-left anterior descending artery (LAD) CTO (A) underwent a second successful procedure via contralateral retrograde approach through a septal channel (B and C). Thrombus was evident at final angiography in the distal segment of the RCA (D). Activated clotting time was maintained above 350 s and manual thrombus aspiration followed, with complete thrombus resolution (E). Courtesy of Dr. R. Garbo.