This is a 65-year-old male with hyperlipidemia and prostate cancer status post operation. The patient suffered from palpitation about 1 year and left atrium myxoma was disclosed by health check-up. Because of LA myxoma, cardiovascular surgery was consulted. Pre-operation coronary angiogram revealed right coronary artery chronic total occlusion. The percutaneous coronary intervention was interrupted due to unstable hemodynamic status last time. The physical exam disclosed no specific finding. 

ECG:Normal Sinus Rhythm Echocardiography:Preserved LVEF with Regional Wall Motion Abnormality seen at the basal-midinferior wall.Blood Investigation:Hb:13.1 g/dL Platelet: 258x10^3/μL BUN: 20 mg/dL Creatinine: 1.11 mg/dL

LeftMain: patentLeftAnterior Descending: luminal irregularityLeftCircumflex: luminal irregularityRightCoronary:-M: 90% stenosis, -D: CTOCollaterals:LAD-Septal to RCA-PDA and LCX-AM to RCA-PLSyntaxScore = 15J-CTO: 2

Bilateral injection confirmed collaterals(RRA with SAL 1/7F in RCA, and LRA with EBU 3.5/7F in LMCA). SionBlue with Cosair Pro MC crossed the RCA-M and escalated GW to Gaia II. To avoid RCA-D bifurcation dissection, Gaia II landing at the RCA-D. For retrograde wiring, Sion with Caravel MC was advanced into LAD-septal branch and confirmed true lumen. Wire escalation to Gaia II crossed the CTO distal cap. Using reverse CART with 2.0/15mm BC, wire externalization with RG3 GW was done. Cosair Pro MC was retrieved with trapping balloon 2.0X15 mm NC. Sasuke MC advanced to RCA-D after POBA over RCA-M with 2.5X15mm BC. SionBlack advanced to -PL, GW de-escalation to Runthrough hypercoat. KBT with 2.0X30mm BC over -PL and 2.0X15mm BC over -PDA. IVUS showed false lumen of -PL with plaque-formatted false bifurcation between -PL and -PDA. Runthrough Extra Floppy advanced to LCX-AM, and SUOH 03 with Caravel MC retrograde wiring to -PL true lumen. After the 2nd time wire externalization, IVUS showed diffuse eccentric fibrous plaque within true lumen of -PL. Then the 2nd time KBT over -PL and -PDA. 2.5X48 mmDES was deployed over RCA-D to -PL with 3.5X20 mm NC post-dilatation. Another 3.5X48 mm DES was deployed over RCA-M to -D with adequate post-dilatation. After post-dilatation with 2.5X15mm NC over -PL, slow flow of -PDA was noted. Re-wiring with Runthrough Hypercoat to -PDA and the 3rd time KBT over -PDA and-PL was done. The final result showed good stent expansion and TIMI 3 flow.

In cases with a high J-CTO score and the presence of collaterals, opting for a retrograde wiring strategy, as we did in this case, can often be the effective approach. Additionally, IVUS is valuable in evaluating the extent of coronary dissection and distinguishing between the true and false lumens. Another valuable lesson from this case underscores the importance of having a backup plan in situations where things don't proceed as expected. Through effective image guidance and differentiation, we carried out the procedure without any complications and preserved all side branches successfully.