A 41-year-old-male presented to our hospital due to chest pain during exertion. He had history of dyslipidemia, obesity, paroxysmal atrial fibrillation and several PCIs; Proximal right coronary artery (RCA) and mid left anterior descending artery (LAD) and distal left circumflex artery (LCx) already was implanted DESs. He had history of anaphylactic shock for iodine-based contrast during last CAG, which could reveal long CTO including in-stent in LAD and not significant stenosis in RCA and LCx.

LAD showed viable with resting single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) by using electrocardiography-gated technetium-99m (Tc-99m). This patient’s symptoms were considered to related to LAD coronary occlusion, and months-long medical therapy appeared to be insufficient. We discussed with heart team, and finally scheduled PCI by using Ga-based contrast

He had history of anaphylactic shock for iodine-based contrast during last CAG, which could reveal long CTO including in-stent in LAD and not significant stenosis in RCA and LCx. D1 branch supply collateral flow into both residual island inside mid-CTO via D3 branch, and LAD distal via tiny apical channel, respectively. However, distal true lumen was ambiguous via collateral channel flow by diagnostic catheter injection.

1:  Compared the pure and half diluted Gd-based contrast with iodine-based contrast2:  Punctured CTO entry with Confienza Pro12 with Corsair Pro 135cm and wire deescalation was performed to track intra-vessel by using Sion Black.3:  Super selective injection to visualize collateral channel by pure Gd-based contrast with Caravel4:  negotiated apical channel by Sion and successfully navigated into LAD distal true lumen. 5:  Antegrade kissing wire technique by Miracle Neo3 andpassed to distal true lumen.6:  Rewiring for separated D3 branch by using tip detection method with IVUS guidance by Confienza Pro12. 7:  Implanted 2DESs for LAD8:  Inserted C-stopper coils due to tiny apical channel perforation to obtain hemostat.9:  Final Angiography. 
The total Gd-based contrast was used only 15 mmol (15 mL).

We performed successful CTO-PCI in patient with anaphylactic shock for iodinated-based contrast by using gadolinium-based contrast. However, there were no gadorinium-related comorbidity during CTO-PCI. Less visibility in fluoroscopy, limitated amount of contrast use and its cost led difficulty in complex PCI like this case.