71 year old man with history of HTN, type 2DM and hyperlipidemiaEx smoker: 1/2 ppd for 30 yrs, quit 1 yearagoRecently, the patient has symptoms ofexertional dyspnea, exertional angina, easily fatiguePhysical examination showed no significantabnormality.

LDL 85 mg/dL; HbA1c 7.6%; Cre 1.1 mg/dLThallium-201 (Tl-201)scan hasrevealed significantreversible ischemiain the inferiorseptal region,which is supplied by the right coronary artery (RCA).So, diagnostic CAG was performed.

Diagnosticcoronary angiography revealed: Chronic total occlusion (CTO) in the rightcoronary artery (RCA) with heavy calcification; Diffuse lesion in the leftanterior descending (LAD) artery; Proximal lesion in the left circumflex (LCx)artery; LAD providing collateral flow to the RCA.After discussion, CTO procedure was performed.

First Procedure: An antegrade approach was initially attempted with wire escalation strategies (using XTA, Fielder FC, Gaia I, II, III, Conquest pro in Cosair), but the wire entered a false lumen. Shift to parallel wire technique with Sasuke. The Gaia III wire eventually reached the distal true lumen. Balloon dilation was attempted, but the CTO segment remained undilatable. IVUS confirmed severe calcification, so a 1.25 mm rotational atherectomy (ROTA) burr was used, which led to mild improvement but still left an undilatable lesion. The procedure was paused because the patient could not tolerate lying flat for an extended time.Second Procedure was performed 3 months later. RCA still showed stenosis despite receiving collateral flow from LAD. Balloon dilation attempts were unsuccessful, necessitating a shift to a 1.75 mm ROTA burr for further plaque modification.After successful lesion modification, further preparation for stenting was performed, followed by the deployment of a 3.0 x 48 mm and a 3.5 x 48 mm drug-eluting stent (DES) in the RCA. Final IVUS confirmed adequate stent placement with good distal runoff. Additional stenting was performed in the LCx and LAD.

For patients who cannot tolerate prolonged procedures, particularly in complex CTO cases, a staged approach utilizing rotational atherectomy followed by drug-eluting balloon (DEB) application can be effective. The DEB provides interim drug delivery, reducing restenosis risk and allowing time for the patient to recover before the next procedure. This approach is especially beneficial for high-risk patients needing multiple sessions for complete revascularization.