A 69-year-old man with a history of type 2 diabetes, hypertension and type B aorta dissection status post stunting. He had angina and accepted stenting at proximal to middle part of left anterior descending artery coronary due to chronic total occlusion one year ago at other hospital.  Few months later, he had progressed angina and went to this cardiovascular out-patient department for further management. Coronary angiography showed type IV in-stent restenosis (total occlusion).

1. LMCA: Luminal irregularity2. LAD: Luminal irregularity, atherosclerosis -P/3 to D/3: s/p stenting with chronic total occlusion (CTO) at P/3 LAD.-D/3: Receiving bridging collateral fainting flow.3. LCX: Non-dominant vessel, luminal irregularity4. RCA: Dominant vessel, luminal irregularity.-P/3 to M/3: s/p stenting.-PL: s/p stenting.

Wires was loaded in microcatheter and crossed proximal to middle total occlusive in-stent restenosis lesion but failed to cross the CTO cap just at distal sent edge. After several attempts. Following angiography showed faint flow pass through the distal stent edge to distal LAD. But the flow seems not to cross the distal stent edge. Escalated wire to conquest Pro 12 with microcatheter and puncture the distal stent cell. The wire finally went into the possible true lumen, after balloon dilation and checked by the IVUS. It was confirmed that the previous stent distal edge was deployed at false lumen. Then ISR lesion was dilated by NC and DEB. Two years later, CAG showed TIMI 3 flow to distal but recurrent ISR at proximal to middle LAD stent. But no total occlusion at distal stent edge.

Usually, the way of wiring the total occlusion lesion which secondary to in-stent restenosis is let the wire at central of stent. However, our wire can’t cross the distal stent edge. Fortunately, following angiography give us a hint that the stent maybe deployed at false lumen, at we did cross into the true lumen from distal stent cell. And it was confirmed by IVUS. We didn’t stent at distal stent edge but dilated it by drug-eluting balloon only. It showed no total occlusion after two years later.