ML, a 67 year old Filipino, male a known case of 3 vessel coronary artery disease with totally occluded LAD, RCA and a known CKD on hemodialysis. Few hours prior to admission patient had chest pain with hypotension and was managed as case of NSTE-ACS. He underwent coronary angiogram which showed the same lesion . He was advised CABG but due to high surgical risk and patient’s consent, he underwent percutaneous coronary intervention.

Transthoracic echocardiogram showed low ejection fraction with segmentalwall motion abnormality. EURO score is 5.92. Creatinine is 3.28 mg/dl

The coronary angiogram showed the a totally occluded left anterior descending artery at the proximal segment, the more distal segment is visualized via right to left collaterals. The circumflex is non-dominant with 70% stenosis. The RCA is totally occluded at the mid segment and the distal vessel is visualized via right to right collaterals.

Dual injection in the left and right coronary artery systems was used to visualized antegrade and retrograde flow to LAD. Initially, antegrade approach was done but failed to cross the CTO of the LAD after multiple attempts. We then proceeded with crossing the CTO of the RCA using a Caravel Microcatheter with Asahi Blue exchanged with Conquest Pro 12 which crossed lesion. After crossing and stenting the CTO of the RCA, the RPDA to the septal perforator was used in the retrograde technique. Initially, Asahi Sion with Caravel Asahi microcatheter was used and was exchanged with Asahi Suoh 3 then Asahi Sion Black up to the distal LAD and was exchanged with Asahi Ultimatebros 3, Asahi Gladius EX14 and finally Asahi Conquest Pro 12 was able to puncture the proximal cap of the CTO retrogradely. The retrograde Caravel was unable to advance more proximally into the LAD, hence, Conquest Pro 12 was advanced in the antegrade Asahi Corsair Pro XS thru the left guide catheter. The Corsair XS Pro was advanced to the distal LAD to meet tip to tip with Asahi Caravel up to the distal LAD. The Conquest Pro 12 was withdrawn slowly while advancing the Runthrough Hypercoat Terumo thru the antegrade microcatheter to the distal LAD. The retrograde wire and microcather was removed then proceeded with successful stenting of the LAD. The circumflex artery was stented prior to stenting the Left main to proximal LAD.

Coronary artery bypass graft is still the recommended procedure for 3 vessel coronary artery disease with left main involvement. However, we have to assess individual risks and how complicated the procedure will be. If complex percutaneous coronary intervention will be the choice, patient should understand the risks as well as the chance of failure and success especially in very difficult cases.