Male  patient, 68 years old , Diabetic , Hypertensive .Ischemic heart disease  with  PCI to LAD 2 years ago .Recurrent chest pain with multiple admissions with ACS during the last 3  months for which coronary angiography was recommended ECG:    SR  with ST , T changes in  inferior leads .ECHO:   IHD with EF 52%, RSWMAs in the form of ( apical and Mid inferior and infero-septal  wall hypokinesia )  with  Moderate  mitral valve incompetence BLPR: 140/90 mmHg , HR : 75 B/M , TEMP: 36.2 c , RBS : 258

Coronary angiography was done showing patent previous LAD stent and CTO RCA  ** Symptomatic patient ** Good EF with SWMA at RCA territory ** Recurrent admissions with ACS And also Thallium study was done to document Ischemic burden of RCA territory and was positive

LM : Normal vessel bifurcating into LAD & LCX.LAD : Atherosclerotic vessel with patent previously deployed stent .LCX: A atherosclerotic small diffusely diseased vessel .RCA : Atherosclerotic vessel with proximal  CTO with bridging collaterals and retrograde good septal and epicardial collaterals from left system

Dual femoral access , Dual injection through AL1 7F & XB4 7F Target vessel assessment ( RCA ) with calculation of J-CTO score then deciding which strategy we decided a Trial antegrade,  If failed , Retrograde through septals , If failed , shift to epicardial collateral.Antegrade Trial with  GAIA Wires , Corsair MC failed , Retrograde trial through septals failed as it seems not connected shifting strategy to epicardial : Sion blue navigated through epicardial collaterals , corsair 150 MC successfully passed through PL branch MC advanced to distal Cap & GAIA 2nd wire successfully pierced distal cap , but failed to entre antegrade guide Trial snaring through AL guiding by a home made snare but failed , Guiding changed to JR with successful snaring of wire into antegrade guide followed by MCPilot 50 wire introduced through retrograde MC  ( Rendezvous Technique , Reverse TIP IN ) then MC Withdrawn we started conventional  PCI with Antegrade Balloon dilatation  2.5 * 15 mm semicompliant   then 3.5 * 15 mm NC balloons   Then stenting with 2 overlapping DES with postdialtation with 4*15 NC balloon with final good angiographic results

** Assessing CC size is mandatory , as sizable epicardial channel can accommodate corsair MC.** Snaring and Rendezvous ( TIP IN ) technique can over come challenges during standard wire externalization .** Short wires ( 180 cm ) NEVER be snared , but if it happens the wire should be pulled out from the antegrade guide , without attempting to retrieve it from the retrograde direction . ** Keep your mind active and  Always be prepared for surprises