A patient with angina was found to have a 99% heavily calcified ostial RCA lesion and inferior ischemia on stress MRI. Engagement of the RCA failed through radial access. We obtained femoral access but still could not engage the RCA due to severe ostial disease and calcification. We used the “air mail” technique: a JR4 guide catheter was pointed towards the RCA followed by advancement of a Sion black wire into the vessel using “trial and error”. The Sion black was exchanged over a microcatheter for a Wiggle wire but the RCA ostium could not be crossed with IVUS. A Viper Flex tip wire was inserted into the distal RCA followed by several retrograde passes of the CSI crown at 80,000 and 120,000 rpm (the crown was advanced into the vessel using Glide Assist and then treatment was done while pulling the catheter back). IVUS showed calcium fracture. After predilatation a 5.0 mm Megatron was implanted and postdilated with an Ostial Flash balloon with an excellent result as confirmed by IVUS.
