The patient is a 69-year-old male smoker with history of hyperlipidemia. He presented with retrosternal chest tightness aggravated by exercise and relieved by for 6 months. Physical examination results were unremarkable. He was started on anti-anginal medications, but his chest pain was refractory to medical treatment.

Electrocardiogram showed anterior Q waves. Trans-thoracic echocardiography showed impaired global left ventricular systolic function with an estimated ejection fraction of 34% by 2D along with regional wall motion abnormalities. Thallium myocardial perfusion scan showed large ischemia regions over anterior and anteroseptal regions.

Left Main: Atherosclerosis, total occlusion since dLMLAD: Atherosclerosis, total occlusionLCX: Atherosclerosis, total occlusionRCA: Atherosclerosis, p-mRCA segmental 60-70% stenosisCollaterals: AM branch of RCA to septal branch of LAD; PL and PDA branch of RCA to LCX

1. An EBU 3.5 SH 7 Fr. guiding catheter to engage LM orifice.2. The XT-A wire to distal LAD with the support of a Caravel microcatheter to pass through the CTO part (antegrade crossing).3. Dilation of the mLAD with SC balloons (1.5x15mm, 2.0x15mm) with 12 bars.4. Difficulty in identifying the LCX ostium on the angiogram, and therefore IVUS-guided puncture was utilized.5. A JL SH 7 Fr. guiding catheter to engage LM orifice (ping-pong guiding). The Runthrough NS Hypercoat wire to the distal LAD.6. IVUS-guided puncture of the LCX. Antegrade wire escalation (Gaia first to Gaia second to Conquest Pro 20 g). The proximal CTO cap was successfully punctured through by Conquest Pro. Injection of contrast through the RCA confirmed that the wire was in the true lumen of the LCX. The Conquest Pro was switched to the Runthrough NS Hypercoat.7. Upfront two stent strategy (DK crush) for LMCA bifurcation. A DES (2.5x32mm) for LM-LCX, a DES (3.5x24mm) for LM-LAD. Another DES (2.5x38mm) for LAD.8. Kissing balloon inflation (4.0x8mm for LM-LAD, 3.0x15mm for LM-LCX). Final POT (4.0x8mm) for LM.

1. Dual injection is imperative in selecting strategy to treat CTO and wire selection.2. When there is vague proximal cap, IVUS-guided puncture may be needed.3. The ping pong guide catheter technique may be utilized to facilitate real time IVUS-guided puncture.