A 39-year-old gentleman with hypertension, dyslipidaemia and aspirin allergy was staged for percutaneous coronary intervention (PCI) to left circumflex artery (LCx) chronic total occlusion (CTO) following a failed attempt 3 months ago. He has exertional angina with Canadian Cardiovascular Society (CCS) angina class II. He had no heart failure symptoms and was hemodynamically stable. Physical examination was unremarkable. 

Haemoglobin level 13.6 g/dlPlatelet count normal at 223 x 10⁹/LCreatinine normal at 72 µmol/LInternational Normalised Ratio 1.0Troponin I normal at 6.5 ng/LElectrocardiogram showed sinus rhythm with T wave inversion over II, III, aVF and V4 to V6 leads.His resting echocardiogram demonstrated preserved left ventricular ejection fraction 69% with lateral wall hypokinesia.

Diagnostic angiogram revealed mild plaque in both left anterior descending (LAD) and dominant right coronary artery (RCA). Target vessel for PCI was proximal LCx CTO with J-CTO score 3 (blunt stump, length > 20 mm, re-attempt) receiving Rentrop 3 collaterals from RCA. There was a ramus intermediate (RI) side branch that bifurcates immediately prior to proximal CTO cap. The LCx CTO was highly angulated from the left main (LM). 

Vascular access via double puncture of bilateral femoral arteries with 7 Fr sheaths. XB 3.5 7 Fr (Cordis, U.S) engaged to LM while JR 4 7 Fr (Cordis, U.S) engaged to RCA for contralateral injection. SION blue (Asahi, Japan) wired to RI side branch and Crusade Type R microcatheter (Kaneka, Japan) advanced till ostial LCx bifurcation. Gladius EX 14 wire (Asahi, Japan) advanced via Crusade side port to attempt CTO puncture, but angle was unfavourable. Crusade exchanged to SuperCross 120 (Teleflex, U.S), providing better approach. Antegrade wire escalation with Gaia Next 1 (Asahi, Japan), ULTIMATEbros 3 (Asahi, Japan) and Gaia Next 2 was successful in crossing CTO. SuperCross 120 exchanged to Corsair (Asahi, Japan) via balloon trapping. Anchor balloon with Trek 2.0 x 12 mm (Abbott, U.S) deployed at RI to assist advancement of Corsair through CTO segment. CTO wire de-escalated to SION Blue. Sequential predilatation with Trek 1.5 x 12 mm and Trek 2.0 x 12 mm at 14 atm. IVUS (Boston, U.S) confirmed true lumen wiring with distal LCx vessel size 2.5 mm and proximal LCx 3.0 mm, minimal calcification. Further predilatation with NC Trek 2.5 x 15 mm at 12 atm, followed by deployment of SeQuent Please NEO 2.5 x 35 mm (B Braun, Germany) at 8 atm for 60 seconds at distal LCx. Proximal LCx prepared with Wolverine 3.0 x 15 mm (Boston, U.S) at 14 atm. Second SeQuent Please NEO 3.0 x 20 mm deployed at 10 atm for 60 seconds at proximal LCx. TIMI 3 flow achieved with minimal recoil and dissection.

This case highlights the successful use of an angulated microcatheter in directing wire position to guide puncture of the CTO cap of an angulated vessel. IVUS is useful to confirm true lumen wiring as well as determining lesion morphology and vessel size. The use of drug coated balloon strategy in this scenario simplifies an otherwise complex strategy of drug eluting stent deployment into the left main with potential carina shift compromising flow into the left main trifurcation.