A 60-year-old male with a history of hypertension, reformed smoking and alcohol use, and coronary artery disease presents with unstable angina. His left ventricular ejection fraction (LVEF) is 55%. Previous coronary angiography (P/CAG) reveals chronic total occlusion (CTO) in the left circumflex artery (LCX) and right coronary artery (RCA).

A 60-year-old male with a history of hypertension, reformed smoking and alcohol use, and coronary artery disease presents with unstable angina. His left ventricular ejection fraction (LVEF) is 55%. Previous coronary angiography (P/CAG) reveals chronic total occlusion (CTO) in the left circumflex artery (LCX) and right coronary artery (RCA). 

Angiography reveals- Double CTO 

The left main (LM) artery was engaged using an EBU 3.5 6Fcatheter. Initial attempts to cross the LCX CTO with Fielder XTR and Gia 3wires were unsuccessful, prompting the use of the Balloon Anchoring Techniquewith a 1x5 mm balloon. Pre-dilatation of the lesion was performed with 1.5x10mm and 2.5x20 mm balloons. A 2.5x40 mm drug-eluting stent (DES) was deployed,followed by proximal optimization technique (POT) using a 2.75x15 mm balloon.For the RCA, an XB 6F catheter was used. Attempts to crossthe RCA CTO with Fielder XTR and Gia 3 wires were unsuccessful, but the lesionwas finally crossed with a Sion Blue wire. Pre-dilatation was performed with a1x5 mm and 2x10 mm balloon. Further pre-dilatation with a 2.5x20 mm balloon wasfollowed by the deployment of a 3x48 mm DES in the distal RCA and a 3.5x40 mmDES in the mid RCA. A 3.5x19 mm DES was deployed in the ostial RCA.Post-dilatation was performed using a 3x15 mm balloon, and a final POT wascompleted with a 3.75x12 mm balloon. 

Managing double CTOs requires advanced techniques such as BAT and guidewire manipulation, especially in patients with a history of unstable angina and comorbidities. In this case, a combination of the Balloon Anchoring Technique and the Guide-Plus inching technique facilitated successful stent deployment in both the LCX and RCA. OCT imaging could be considered in future cases to enhance precision. The successful final result without complications underscores the importance of using tailored strategies for complex CTO interventions. Lifestyle modification will remain crucial for long-term outcomes, especially given the patient's history of smoking and alcohol use