A patient with prior CABG (LIMA-LAD, SVG-RCA, SVG-OM – SVG to OM was known to be occluded) presented with NSTEMI. LIMA-LAD was patent as was the SVG-RCA. The culprit vessel was considered to be the circumflex that had a severe ostial lesion and was filling retrogradely via the LAD, which was in turn filling via the LIMA. Baseline hemodynamics were poor (wedge pressure = 21 mmHg), which is why the patient was admitted to the ICU for diuresis. Hemodynamics significantly improved and the following day he returned to the lab for attempting PCI of the LM CTO into the circumflex. A Gaia Next 2 wire advanced through a Corsair microcatheter successfully crossed into the ramus branch but the microcatheter could not follow. After predilatation with a 1.0x15 mm Sapphire Pro balloon we were able to advance a microcatheter into the ramus and exchange the Gaia for a workhorse guidewire. Multiple attempts to wire the circumflex, even using a Sasuke dual lumen microcatheter failed. A Sion black wire was knuckled at 3 cm from the tip and inserted into the ramus, entering the circumflex upon withdrawal (reversed guidewire technique). Once again, we had difficulty advancing the microcatheter into the circumflex and a microcatheter could not cross. A Sapphire 1.0 mm balloon failed to cross, but was eventually successful using the side branch anchor technique. After provisional stenting (from left main into the circumflex) we achieved an excellent final result as confirmed by IVUS.
