A 50's male developed a STEMI eight months ago. An Emergency CAG revealed total occlusion of mid LAD and moderate stenosis of LMT to proximal LAD. At that time, DES was implanted for mid LAD. One month later, staged PCI was attempted for LMT-LAD. However, a DCA catheter got stuck with the implanted stent, and the stent was removed together with the DCA catheter. Due to luminal enlargement without significant vessel injuries, the procedure was terminated after the application of DCB for LMT-LAD.

Electrocardiogram revealed QS pattern and terminal T inversion in V1-4 leads. Echocardiography showed LV ejection fraction was 44% with anterior wall hypokinesis. Renal function was normal limits on laboratory data.

Seven months later, a follow-up coronary angiogram was performed. The angiogram revealed no significant stenosis in the RCA, severe stenosis lesion at the true bifurcation of LMT, and reocclusion in mid LAD. The CTO entry is shown to be tapered type, and septal collaterals from PDA to LAD.

The strategy involved using an 8F guiding catheter and attempting antegrade wiring for the LAD-CTO, followed by a rescue retrograde approach procedure. We used IABP from the beginning due to severe stenosis at LMT. Initially, LAD and LCX were wired using a dual lumen catheter, and dilated LMT bifurcation with KBT. Next, the antegrade wiring with the XT-R failed to pass the mid LAD-CTO lesion, so we switched to Gaia Next 1 and successfully achieved antegrade wiring. The CTO was sequentially predilated with 2.5mm balloon, and 2.5mm DES stent was deployed at the CTO lesion. The proximal LCX was dilated with 2.5mm balloon, and 3.5mm DES stent was deployed at the LMT-LAD lesion. The LCX wire was recrossed, and final KBT was performed using 3.0mm balloon in the LMT-LAD and 2.5mm balloon in the proximal LCX. Finally, DCB was used at LCX ostium.

In this case, the DCA catheter became trapped in the implanted stent, resulting in the removal of both. A few months later, a coronary angiogram revealed a CTO at the same site, which was successfully treated using an antegrade approach. There was also severe stenosis at the LMT bifurcation, and the use of an IABP from the beginning allowed the procedure to be performed with stable circulatory dynamics. Finally, the treatment could be completed with a single stent over the LMT-LAD.