A 67 year-old man was admitted to evaluate and manage the coronary vessels. He has a history of diabetes and has been taking medication in our edocrinologic department. During the follow up the thallium scan was performed. That thallium scan showed abnormal finding suggesting coronary artery disease (Figure 1). Because of this abnormal finding of thallium scan, we decided to take coronary angiogram. Baseline coronary angiogram showed 60% narrowing of distal left main, diffuse 70% narrowing of distal LAD and diffuse 90% narrowing of distal LCX, total occlusion of proximal RCA (Figure 2, Figure 3, Figure 4, Figure 5). After coronary angiogram, two stents with Cypher 3.5X28mm in left main os to proximal LAD, Cypher 3.5X13mm in distal left main to proximal LCX were implanted with crushing technique(Figure 6). And then, staged PCI about total occluded RCA lesion was decided.

1. Right coronary angiogram showed TIMI 0 flow from proximal RCA (Figure 5)
2. Left coronary angiogram showed stent in the LM to proximal LAD and proximal LCX. And collateral branch from LAD to RCA via septal branch was shown (Figure 7)

Right coronary ostium was cannulated with an 8 Fr Judkin 4.0 guiding catheter and left coronary ostium was engaged with a 6Fr Judkin catheter for contralateral angiogram. Initially, by using a Finecross® 0.014 inch 1.8 Fr -130cm microcatheter, the Fielder XT 0.014 inch guide-wire was advanced (Figure 8). However, the first guidewire passage failed and entered into the subintima (Figure 9, Figure 10). Therefore, a Miracle 3 0.014 inch guide-wire was advanced to the distal part of the total occlusion leaving the Fielder XT wire in place (Figure 11). By this parallel wire technique, the Miracle 3 guide-wire succeeded to cross total occlusion (Figure 12, Figure 13). After removing of Fielder XT wire in subintimal portion, pre-dilation was performed at proximal to middle RCA with 2.5 X 15mm Ryujin balloon (Figure 14). After this pre-dilation, a 3.5 X 33mm Cypher stent (by 10atm, 3.5mm) was implanted in the proximal RCA (Figure 15). Then, additional post-dilation was performed with a stent balloon (Figure 16). The angiogram after stenting showed mild residual lesion at mid to distal RCA (Figure 17). However, another angiogram showed dye staining presenting a perforation of small branch of distal RCA by the guidewire(Figure 18, Figure 19). For the treatment of this perforated distal branch of RCA, the 0.014 inch BMW guide-wire was advanced to the perforation related branch(Figure 20). Ant then, long duration of ballooning with 2.0X15mm Ryujin balloon was performed. After then, gelform insertion was done by using a Finecross® 0.014 inch 1.8 Fr -130cm microcatheter(Figure 21). Final angiogram showed successful revascularization at RCA CTO lesion and no progression of dye staining in the pericardium(Figure 22).