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A 43-year-old malenon-smoker with hypertension and dyslipidemia reported intermittent chesttightness for about 6 months. After evaluation, he received coronaryangiography at another hospital. It showed triple-vessel-disease, with chronictotal occlusion since orifice of left anterior descending artery (LAD).Percutaneous intervention for LAD failed so he was referred to our hospital. Weoptimized his medication but he was still symptomatic.

His ECG showed sinus rhythm, withnon-specific T wave change in inferior leads Echocardiography showed left ventricularhypertrophy, with adequate left ventricular systolic function.

Coronary angiography showed triple-vessel-disease: CTO since orifice of LAD, about 70-80% stenosis at LCX and 70-80% stenosis at RCA. The CTO part was long, from proximal to middle LAD. There were collateral channels from RCA to LAD. 

1. EBU4 for antegrade; SAL1(SH) for retrograde. 2. Antegrade approach: XT-R wire in Codmanmicrocatheter. The wire to proximal LAD, but we could not send Volcano IVUSdown to make sure the wire was in true lumen. 3. Retrograde approach: Runthrourgh wire to distalRCA. DES stent (3.0/24mm) for middle RCA after pre-dilatation with 2.5mm balloon. 4. SION wire in Corsair microcatheter to distal PDA. TheSION wire passed septal channel to distal LAD.5. However, Corsair could not pass septal channel,even with 1.5/15mm balloon anchored. We changed to Finecross microcatheter. Finecrosspassed septal channel but a 130cm Finecross was not long enough to reachproximal LAD. 6. We retrieved the whole retrograde system and made a new shorter guiding catheter. Then, we passed septal channelagain with SION. 7. We then used Gaia first to wire through the CTOpart via retrograde direction. With retrograde wire as guidance, we wiredthrough the total occluded part from antegrade direction with Gaia second. Then, we changed to SION wire to distal LAD. Fielder FC wire to LCX. 8. IVUS showed SION wire all the way in true lumen.9. After pre-dilatation with 2.5mm balloon for bothLAD and LCX, 2 DES (2.5/38mm and 3.0/38mm) for LAD and 1 DES (2.5/38mm) forLCX. 10.IVUS showed good stent apposition. Finalangiography showed good result. 

This is a case with LAD CTO with failedPCI. We re-tried with antegrade approach but was unable to make sure if thewire was in true lumen. Retrograde approach was indicated and we successfullypassed collateral channel. However, a longer microcatheter was not available sowe had to make a shorter guiding catheter to go on the procedure. When dealingwith CTO, sometimes crossing the total occluded part is not enough. Deviceissue is one of the obstacles. A home-made short guiding catheter may be thesolution in some circumstances.