Mr.PK

37 year old male presented with angina on exertion. CCS Class III. Patient is chronic smoker, hypertensive as well as non-diabetic. Electrocardiography was normal and their was no regional wall motion abnormality. With left ventricular ejection fraction of  50%.Coronary angiogram showed
LM normal
LAD 100% occluded from mid segment and filling retrogradely by homogenous collateral from septal LCX 100% occluded proximally non dominant vessel
RCA mid  segment 99 percent stenosis dominant vessel. 

echocardiography was normal and EKG showed no changes

LM- 50% stenosis
LAD- Mid 100% CTO filling retrograde by septal collaterals and RCA
LCx- Proximal 100% CTO
RCA- Mid 99% concentric focal stenosis

Angioplasty-Step 1- Through right femoral XB 7F was engaged and lesionwas tried to cross antegradely but failedStep 2- Hence wire was crossed via septal (Homogenous)collateral to LAD and over the wire fine cross was taken and parked in LADStep 3- Wire was escalated to GAYA 2 and lesion was crossedand wire was parked in same guideStep 4- Fine cross was passed over the wire and parked inguide at its mouthStep 5- Near the angle of XB 7F and thus fine cross wastaken antegradely and was parked over retrograde wire using Tip-In Technique intothe lesion distallyStep 6- Wire was removed retrogradely and antegradely wirewas parked in LAD with the help of exchanged micro catheter.Step 7- Afterexchanging antegrade wire vessel was predilated with 1.5*10 & 2*10 NCBalloonStep 8- 3.50*48& 3*32 DES was deployed from proximal to mid to distal LAD across itsentire lengthStep 9-After deployment post dilatation was done with 3.5*10 NC balloon with goodTIMI- III flow but suddenly there was di-stasis and dissection in the distal LMand patient went into bradycardia and immediately 4*19 DES was deployed as arescue angioplasty.Step 10-Subsequently patient had on going angina and RCA was having 99% lesion hencePTCA to RCA was done with good TIMI-III flow.Patient isunder follow-up and doing well.  

Retrograde using  single catheter  via  homogenous collateral  poses  greater challenge.  In  this case  it  was  difficult  to  push in  micro  catheter into  same  guide, hence  tip-in  technique was  used  where antegrade  micro  catheter was  parked  over the  retrograde  wire  and then  it  was  parked  in mid  LAD  and antegrade  wire  was taken.  Tip-in  is an  excellent  technique  requiring  correct  understanding  of  branch, angle  of  guide and  poses  a great  technical  challenged.