AP

A 57 years old male was planned for elective PCI CTO in RCA with J-CTO score 2 and Werner score CCS 2 . His risk factor is hypertension, had CABG X2 ( LIMA-LAD, SVG-PL) 3 years prior to admission. He presented with stable angina pectoris CCS II and graft failure in SVG-PL.  His physical examination is normal, and hemodinamically stable. 

ECG: Normal Sinus Rhythm with slight T inversion in lead AVL  
Echocardiography: LVEF (teich) : 57% with Regional Wall Motion Abnormality seen at  basal-mid inferior and slightly decrease RV function ( TAPSE 1.6 cm)
Blood Investigation: Hb:  14.7 g/dL   Platelet: 281.000           Ureum:  30.5  mg/dL            Creatinine: 1.08 mg/dL

Coronary Angiography findings: Native Vessel:Left Main: normalLAD: CTO at proximal with bridging collateral LCx: Tubular stenosis 80-90% at distalRCA: CTO at mid with collateral bridging, distal filling from ipsilateral and contralateral ( Rentrop II ) 
Graft Vessel:LIMA-LAD : Graft patent SVG-PLB: Total occlusion at osteal 

Dual injection was performed ( transradial with guiding JL 3.5/6F cannulated in LCA , and transfemoral with guiding AL 1/6F cannulated in RCA).  Gaia II and Gaia III failed to cross the lesion antegradely in proximal RCA with microcatheter Finecross 1.8F/130 cm due to imprecise distal. Wiring with workhorse wire through the left system, crossing the septal LAD and placed as a marker wire in PL branch retrogradely with microcatheter Finecross  1.8F/150 cm. Unfortunately the microcatheter failed to cross the PL branch. Continue the antegrade technique with escalating wire Conquest Pro 12 and successfully crossed the lesion and placed in PDA. Anchor balloon SC 2.0/15 mm was inflated in proximal RV branch to facilitate microcatheter to distal RCAExchange wire to workhorse wire in distal RCA. Retrograde marker wire was withdrawn and guiding JL in left system was disengaged.  Predilate with balloon 3.0/15 mm from proximal to distal with 10 atm. Everolimus stent 2.5/38 mm was implanted from mid to distal before PL-PDA bifurcation with 11 atm Everolimus stent 3.0/38 mm was implanted from proximal to mid ,overlap from previous stent with 10 atm Everolimus stent 3.5/24 mm was implanted from osteal to proximal, overlap from previous stent with 10 atm (full metal jacket)Postdilatation and flair with balloon ex-stent (3.5/24 mm) was inflated with maximum pressure of 16 atm intrastent. Total flurotime was 90 minutes, last evaluation: TIMI 3 flow, no perforation, no dissection, no residual stenosis.

This case showed the necessity to have a backup plan when things did not go our way.  J-CTO score of 2 showed only 34.8% success rate in crossing the lesion less than 30 minutes. Another lesson learnt from this case would be not to force the retrograde microcatheter to pass the stuck passage near the PL branch owing to the fact it would cause perforation which could lead to pericardial effusion. The retrograde marker wire allowed us to guide the antegrade wire finding the true lumen along the vessel. The uncrossable antegrade microcatheter was solved with no harm by doing anchor balloon at proximal RV branch. Understanding the steps allowed us to accomplish the procedure well.