A 76 year-old man was admitted for efforting angina. He underwent PCI at mid to distal RCA lesion with DES at 2010 in another hospital. Recently, the chest discomfort was aggravated with maximal medical therapy.

He had coronary risk factors such as hypertension, dyslipidemia and ex-smoking history with 10 pack-years. As a non-invasive function test, thallium SPECT was done and showed fixed large size perfusion defect of RCA territory but partially reversible medium sized perfusion defect in LAD territory. Treadmill test was negative. The trans-thoracic echocardiography showed mulitiple regional wall motion abnormalities with severe LV systolic function (EF=33%).

1. A left coronary angiogram showed diffuse intermediate lesion at pLAD and total occlusion from mLAD with TIMI 0 flow. ( Movie 1) 2. A right coronary angiogram showed patent stent at dRCA, grade 3 collateral flow was shown from PAD to LAD ( Movie 2).

Firstly, left coronary ostium was cannulated with an 8 Fr EBU 4.0 guiding catheter and right coronary ostium was positioned with 6 Fr JR4 diagnostic catheter( Movie 3).Initially, by using a PCI-guide wire; soft 0.014’’-175cm was passed through LAD to septal branch. The exact stump point of LAD was achieved with IVUS-guidance. The guidewire (Fielder FC 0.014 inch 180 cm) was advanced into septal collateral to LAD, but the guidewire could not be passed into true lumen of LAD due to dissection. Secondly, we changed diagnostic catheter into 7 Fr AR2 guiding catheter at RCA. A Fielder FC 0.014 inch 180cm guidewire with a Finecross® 0.014 inch 1.8 Fr -130cm microcatheter was approached to retrograde pathway to LAD. ( Movie 4). Due to tortuosity, the wire was changed to Corsair 0.014 inch 150cm (septal dilator) with guide wire; SION 0.014’’-175cm was used (Figure 1). A SION 0.014 inch 175cm guidewire with a Finecross® 0.014 inch 1.8 Fr -130cm microcatheter was successfully advanced to mid-to distal LAD. And then, Corsair 0.014 inch 150cm (septal dilator) was used in microchannel dilatation (Figure 2). An Ultimate 3 0.014’’-175cm guidewire with OTW Ryujin 1.25(10) was advanced into antegrade approach. Using CART technique, small balloon (Ryujin 1.25 * 10) were used in subintimal space creation in antegrade direction (Figure 3). After then, retrograde wire was externalized into LAD guiding cathter and multiple balloon dilatations (Black Hawk 2.5(16)) was performed. Conquest pro 0.014’’-175cm and Fielder FC 0.014’’-175cm guidewire was inserted into LAD by antegrade approach, then Fielder FC 0.014’’-180cm and Extension 0.014’’-175cm was passed through the LAD( Movie 5). The LAD angiogram showed diffuse stenosis in proximal to mid LAD (Figure 4). The consecutive two Cypher-select (3.0*23mm+2.5*33mm) were deployed at proximal to mid LAD ( Movie 6, Movie 7). The final angiogram showed well positioned and expanded stent with good distal run-off flow. ( Movie 8, Movie 9, Movie 10)