This is a 72-year-old male patient presented with chest tightness for days, then he was brought to our hospital. He had underlying disease of hypertension, diabetes mellitus, Dyslipidemia, Sick sinus syndrome, status post permanent pacemaker implantation and atrial fibrillation under chronic medical treatment. Physical examination showed irregular heart beats and mild lung congestion. Thallium scan revealed positive and invasive coronary angiography was indicated.

Thallium scan
Stress- induced ischemia at inferolateral to inferior wall(medium extent) is favor

CAD/LM+3VD, distal RCA 90% stenosis, PL CTO, distal LM 70% stenosis,   proximal to middle LAD 80% stenosis, distal LAD myocardial bridge,   middle  LCX 50% stenosis, s/p DES*2 at LM-mLAD, antegrade failure    approach PL branch on 2024/03/13, successful retrograde approach for  PL from epicardial  channel, s/p DES*2 at m-dRCA to PL on 2024/04/10.

1. We tried to used SAL1/SH/7F guiding catheter to engage RCA orifice    and EBU3.75/SH/6F for LM orifice to have bilateral injection.    2. The runthrough wire to PDA and used IVUS to view proximal PL CTO    CAP and localized at fluoroscopy.    3. We tried a Caravel microcatheter with fielder FC to explore PL CTO    antegradely, then tried Gaia II, but failure to advance.    4.We tried retrograde approach through LCX epicardial channel.    5.We used caravel microcatheter with SIOH and SUOH wire and    successful reach proximal PL CAP, but failure to advance due to the    hard texture.    6.We tried Gaia II and Conquest Pro, and successfull retrograde reach    distal RCA.    7.Due to Caravel couldn't advance to PL proximal Cap, we used Ryurei    balloon and mini TREK 1.5*6 balloon to dilated PL with 14 bars.    8. The conquest pro 9 wire was tip in antegrade microcatheter and    tried to use fielder FC to reach PL.    9. We used a TREK 2.5*15mm balloon to have kissing technique at PL    and PDA.    10.A Xience sierra 3.0*33 stent was deployed at dRCA to PL with 10    bars.    11.A Xience sierra 4.0*33mm stent was deployed at dRCA with 10 bars.    12.Post stent dilatation with a NC TREK 4.5*15mm balloon NC TREK    3.0*15mm balloon with 20 bars.    13.IVUS showed well stent expansion.    14.Final angiography showed better RCA flow and no extravasation at LCX epicardial channel.

 CAD/LM+3VD, distal RCA 90% stenosis, PL CTO, distal LM 70% stenosis, proximal to middle LAD 80% stenosis, distal LAD myocardial bridge, middle  LCX 50% stenosis, s/p DES*2 at LM-mLAD, antegrade failure    approach PL branch on 2024/03/13, successful retrograde approach for  PL from epicardial  channel, s/p DES*2 at m-dRCA to PL on 2024/04/10.