A patient with prior CABG was referred for PCI of a mid RCA chronic total occlusion. The CTO had a blunt proximal cap at the takeoff of an acute marginal branch. Antegrade wiring through a Sasuke microcatheter failed, as did retrograde crossing attempts via a septal collateral. An IVUS catheter was advanced into the acute marginal branch clarifying the location of the proximal cap, followed by IVUS-guided proximal cap puncture with a Hornet 14 wire. The Hornet 14 was exchanged with a Mongo wire that entered a 2nd acute marginal branch. The proximal cap was balloon uncrossable but using a Sapphire 1.0 mm balloon and a Trapliner we advanced a Caravel microcatheter distally. The side BASE technique (balloon inflated halfway in and halfway out the 2nd acute marginal branch followed by advancement of a knuckle wire around the origin of the side branch) allowed subintimal crossing distally. Attempts to re-enter with a Stingray balloon failed, as did a retrograde crossing attempt via an epicardial collateral. The STRAW technique was performed using a balloon inflated in the mid RCA along with a Caravel microcatheter delivered distally through which aspiration was performed. Re-entry was successful with a Stingray balloon using the double-blind stick and swap technique with an Astato 20 guidewire. The Stingray balloon was also used for advancing a guidewire into the PDA, followed by stenting with a nice final result.
