A patient presented with significant angina and was found to have inferior ischemia on nuclear stress testing. Coronary angiography showed an RCA CTO with moderate disease in the LAD and circumflex. The patient was referred for PCI of the RCA CTO. Antegrade wiring failed. We decided to try retrograde crossing via a septal collateral that also failed (no continuous septal connection). IVUS of the LAD and circumflex showed significant disease in the proximal LAD and proximal circumflex, that were successfully stented using the DK crush technique. Attempts for retrograde crossing via an epicardial collateral from the circumflex failed.
We changed back to antegrade crossing but had difficulty advancing a guidewire past the proximal cap. We used the BASE technique and were able to advance a Gladius Mongo to the mid RCA. The microcatheter could not advance past the proximal cap (balloon uncrossable lesion). After using a Sapphire 1.0, multiple 1.5 mm balloons and a 6 French Trapliner we were able to deliver a Stingay balloon to the distal RCA, but reentry failed. Attemps to reenter using a ReCross microcatheter also failed. We used the STRAW technique with an OTW balloon but still Stingray-based reentry failed. A knuckled wire was advanced to the PLV into the distal true lumen. Balloon angioplasty of the entire was performed followed by fenestration of the PDA with a knuckled Gladius Mongo wire. TIMI 3 flow was restored in the RCA but no stents were placed due to extensive dissections past the PDA/PLV bifurcation. This was an investment procedure with plan to return in 2 months for repeat attempt to perform PCI of RCA CTO.

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