A 54 year-old man was admitted for efforting angina. He underwent PCI at mLAD at 2007 in another hospital but follow-up angiography showed instent restenosis, so received bypass graft surgery using off-pump method with LIMA to LAD and TRA to OM graft at 2008. March. He felt comfortable after CABG but recently suffered from efforting angina.

He had a history of smoking with 30 pack-years. He did not have other coronary risk factors. Treadmill test showed ST depression in stage IV. The trans-thoracic echocardiography revealed RWMA in RCA territory with mild decreased LV systolic function (EF=45%).

1. A right coronary angiogram showed TIMI 0 flow proximal, near ostium, portion of RCA with collateral from LAD with relatively enlarged RV branch. ( Movie 1)
2. A left coronary angiogram showed distal instent restnosis in previous deployed stent in mLAD lesion. ( Movie 2)
3. All grafts were patent in coronary angiogram and CT coronary angiography.

Firstly, left coronary was cannulated with a 8 Fr EBU 4.0 guiding catheter (hand-cutting short guiding) and right coronary was inserted with JR4 7 Fr SH guiding catheter. Initially, by using a ASAHI Corsair ® 0.014 inch 2.8 Fr -150cm Coronary Micro-Guide catheter, 0.014 inch Fielder FC wire was tried into septal branch across the previously deployed stent strut. ( Movie 3) After crossing the stent strut, contrast injection via micro catheter showed no septal connection into RCA branch, for several times. (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5) At last, 4 th septal branch was successfully negotiated with distal PD brach. (Figure 6, Figure 7, Figure 8, Figure 9) During negotiation, We used Fielder XT and Fielder FC coronary wire, alternatively. After cross over septal collaterals, knuckle wire technique for retrograde subinitmal tracking was performed. (Figure 10) And then, another 0.014 inch coronary guidewire was inserted into RV branch for landmarking in intervention. (Figure 11)

For antegrade direction, 0.014 inch Fielder FC wire was tried, but due to some resistance, the soft wire could not advance, so, we changed into Miracle 3.0 g hard wire for antegrade advance. Fortunately, hard wire was successfully advanced to retrogradely advanced wire. (Figure 12, Figure 13)

We performed several balloon dilatation with Ryujin 1.25 sized balloon, Sprinter 1.5 sized balloon and Ryujin 2.5 sized balloon, sequentially. (Figure 14). Thereafter Retrograde wire was advanced into RCA guiding catheter and ASAHI Corsair ® 0.014 inch 2.8 Fr -150cm Coronary Micro-Guide catheter was advanced into RCA guiding catheter. ( Movie 4) Retrograde wire was changed into Fielder FC long wire (300 cm) and externalized into outside of antegrade guiding catheter.

After several predilation, We deployed #4 stent firstly Xience-V 2.5 * 28 mm, secondly Taxus-Liberte 3.0 * 38 mm, thirdly Xience-V 3.5 * 28mm in RCA, and finally Xience-V 2.5 * 28 mm in RCA to PL branch. (Figure 15, Figure 16, Figure 17, Figure 18)

Final angiogram showed successful stent expansion without periprocedural complications. (Figure 19, Figure 20)