44 yrs/ Male Anterior wall Myocardial Infarction  [2021]Attempted PTCA to LAD on 17/6/2021Echo s/o Ischemic Heart Disease  LVEF 30% Lad territory akinetic with preserved wall thicknessMild MR , NO PAHOn regular medication

2D ECHO s/o Ischemic Heart Disease LVEF 30% Lad territory akinetic with preserved wall thicknessMild MR, No PAH

CORONARY ANGIOGRAPHY SINGLE VESSEL DISEASE LAD VESSEL CTO LESION  RETROGRADLY FILLING WITH MAJOR VESSEL OM AMBIGUOUS CTO CAP , BLUNT TIP LCX DOMINANT VESSEL NORMAL RCA NON DOMINANT NORMAL 

DIFFICULTIES-BLUNT/AMBIGUOUS STUMP  PREVIOUSLY ATTEMPTED. PLAN: ANTEROGRADE APPROACH VS  RETROGRADE APPROACH.ASAHI SUOH 03 WIRE ENTERING THE EPICARDIAL CHANNEL INTO LAD.WIRE EXCHANGED TO  PILOT 150.RETROGRADE WIRE ESCALATION.WIRE EXCHANGED TO CROSS IT 200.WIRE CROSSED INTO THE CTO SEGMENT.BUT INSTEAD OF GOING INTO LAD IT WAS GOING IN SEPTAL OR DIAGONAL BRANCH .AFTER TRYING FOR 5 MIN WE THOUGHT OF SOMETHING DIFFERENT !!! WE PLANNED TO GO ANTEGRADELY, TOOK PILOT 150 WIRE.TOOK CROSS IT 200 WIRE OVER A FINECROSS CATHETER.COULD CROSS THE STUMP AND WENT INTO DIAGONAL.MICROCATHETR WAS CROSSED INTO DIAGONAL AND WIRE WAS REMOVED.A SMALL INJECTION WITH MICROCATHETER CONFIRMED THE INTRALUMINAL POSITION OF MICROCATHETER.RETROGRADE WIRE WAS MARKER FOR DISTAL LAD. SLOWLY WIRE WAS ADVANCED TO LAD PRE DILATED WITH 1.5X15 MM F/B 2.0 X15 MM BALLOONS 12 ATM.3.0X40 MM SIROLIMUS DRUG ELUTING STENT WAS DEPLOYED AT 12-14 ATM IN OSTIAL PROXIMAL LAD LESIONTHERE WAS A DIFFUSE DISEASE IN DISTAL LAD, HENCE ANOTHER
44 MM DES WAS TAKEN OVERLAPPING WITH EARLIER STENT 2.5X44MM SIROLIMUS DRUG ELUTING STENT WAS DEPLOYED AT 14-16 ATM, IN MID LAD LESION. OSTIO PROXIMAL SEGMENT POST DILATATION WITH 3.5 X 12BALLOON. SUCCESSFULLY PTCA TO LAD DONE WITH 2 DES WITH TIMI 3 FLOW .              

1. RETROGRADE APPROACH IS A GOOD OPTION FOR CTO, provided we handle them very carefully2. antegrade should be the preferred approach.3.Wire escalation should be done carefully depending on lesion subsetHardware including snares/wires/microcatheters/guide catheter are key for complex interventions