A 59 year-old male presented with stable angina pectoris. 15 years ago, he underwent coronary angiography and stenotic lesion of the mid LAD was successfully treated with two bare-metal stents. 5 years later, he suffered from recurrent angina and underwent coronary angiography. His coronary angiogram revealed multiple stenosis of coronary artery including mid LAD ISR and three BMS were deployed at mid LAD ISR, LM-proxmial LAD, and proximal LCX. His risk coronary factors were hypertension, dyslipidemia, and smoking. ECG showed non-specific ST-T changes in inferior leads. Echocardiography showed a basal inferior wall hypokinesia with preserved LV systolic function. About 1 months ago, in 2010 CTO summit in Asan Medical Center, first trial to open the occluded lesion was performed but unfortunately failed.

1. A right coronary angiogram showed a diffuse stenosis of from mid to proximal RCA and sequential 100% occlusion of mid RCA.(Figure 1)
2. A left coronary angiogram demonstrated patent previous stents and the distal RCA was filled via left-to-right collaterals both from LCX and septal perforator.(Figure 2)

The RCA was engaged with AL1 7Fr SH guiding catheter and left coronary was engaged with 8 Fr XB 3.5 SH guiding catheter. The left guiding catheter was shortened with hand-cutting by operator. We tried to pass a 0.014 inch Fielder FC 180cm wire which was loaded onto a Corsair 1.8 Fr 150cm channel dilator catheter (Asahi Intec, Abbott Vascular). This system was advanced into the distal RCA retrogradely via epicardial collateral from LCX.(Figure 3) The wire was changed into a 0.014 inch Fielder XT 180cm. The retrograde wire entered the subintimal space and advanced into the CTO lesion of mid RCA. The “knuckle wire technique” was intentionally used for subintimal tracking.(Figure 4) We approached antegradely with Finecross 1.8 Fr 130cm with Fielder FC 0.014 inch 180cm. We performed antegrade balloon dilatation to create a plaque dissection and modification with Ryujin 2.5 mm * 20 mm, Apollo 3.5 mm * 15 mm balloon, sequentially.(Figure 5) The Volcano Virtual Histology was used for check of lumen characteristics. The VH showed heavy calcified, relative large vesse diameter and antegrade wire was placed in the true lumen. The soft (Fielder XT) retrograde wire was failed to advance to antegrade space, so changed to the Conquest pro 0.014 inch 175cm. The Conquest pro wire could not be passed into the mid RCA lumen. Additional antegrade balloon dilatations were done with Voyager 4.0 mm * 15 mm and then the retrograde wire was advanced into the mid RCA lumen successfully. After advancing Corsair system across the occlusion site, the regtrograde wire was exchanged for a RG-3 0.010 inch 330cm wire. The retrograde wire was advanced into the antegrade guiding catheter and externalized.(Figure 6) Additional predilation via antegrade approach was performed with Ryujin 2.5 mm * 20 mm balloon over the externalized RG-3 wire. The sequential four PRMUS-E stents (2.5*28 + 3.0*28+3.5*28+4.0*28) were deployed from distal RCA to proximal RCA.(Figure 7) The final angiogram showed well positioned and expanded stents with good distal run-off flow ( Movie 1) without any complication.( Movie 2) The follow-up echocardiography showed no evidence of pericardial effusion.