A 73-year-old man, ex-smoker, with hypertension, dyslipidemia, and ischemic heart disease was electively admitted for staged percutaneous coronary intervention (PCI) to a chronic total occlusion (CTO) of the left anterior descending artery (LAD). The patient refused coronary artery bypass grafting (CABG). He reported occasional angina, Canadian Cardiovascular Society (CCS) Class II. Physical examination was unremarkable with blood pressure 145/65 mmHg and pulse rate 67 bpm.

Hemoglobin 13 g/dL, urea 6.7 mmol/L, and creatinine 114 µmol/L. Electrocardiogram showed sinus rhythm, and chest radiograph revealed clear lung fields.

The LM had 50% ostial stenosis. LAD showed proximal CTO with bridging collaterals from the right coronary artery. LCx demonstrated proximal CTO with contralateral collaterals from the RCA. The right coronary artery was dominant with mild disease. The case represented complex dual CTO with LM involvement, posing both technical and procedural challenges due to tortuosity and calcification.



RAO Caudal COROS video.mov
RAO Cranial video COROS.mov
LAO caudal Coros Video.mov

A dual access strategy was used: right radial for RCA and right femoral for LCA. For LCx CTO PCI, a Finecross microcatheter (Terumo, Japan) was advanced to the distal LCx. Predilation was done using a 2.5 × 15 mm Firefighter balloon (Medtronic, USA) at 8 atm, followed by stenting with a 3.5 × 30 mm Orsiro Mission drug-eluting stent (Biotronik, Germany) at 16 atm. Postdilation was performed with a 3.0 × 15 mm Accuforce non-compliant (NC) balloon (Terumo, Japan) at 14 atm.For LAD CTO PCI, Finecross with Fielder wire (Asahi, Japan) failed to cross; Gaia First (Asahi, Japan) successfully reached the distal LAD. Predilation was performed using NC Sapphire 24 (OrbusNeich, Hong Kong) 3.5 × 12 mm and Wedge NC (Boston Scientific, USA) 3.0 × 15 mm. A 3.0 × 40 mm Biofreedom Ultra stent (Biosensors, Singapore) was deployed at 14 atm. Proximal dissection into LM was noted, requiring LM–LAD stenting with 3.5 × 22 mm Orsiro Mission and proximal optimization technique (POT) using 4.5 × 18 mm NC Emerge balloon (Boston Scientific, USA). Intravascular ultrasound (IVUS) revealed ostial–proximal LCx disease, confirming a bifurcation lesion. Ostial LCx was predilated with a 3.5 × 12 mm NC Sapphire balloon and stented with a 3.5 × 14 mm Biofreedom Ultra. Final kissing balloon inflation was done with NC Sapphire 3.5 × 12 mm (LAD) and 3.5 × 14 mm (LCx), followed by final POT with NC Emerge 4.5 × 8 mm balloon at 18 atm. Final shot revealed TIMI 3 flow with no dissection or perforation. 



Stent lcx video.mov
Stent LAD video.mov
Final flow.mov

This complex case of dual CTO involving LM bifurcation was successfully treated using a dual access approach, multiple wire strategies, and IVUS-guided optimization. The procedure demonstrates that percutaneous revascularization can be a feasible alternative for surgical turn-down patients when performed with meticulous planning and imaging guidance. Optimal outcomes were achieved with POT and final kissing balloon techniques, restoring full coronary flow. This case highlights the evolving capability of complex PCI to address high-risk anatomy traditionally managed by CABG.