- Relevant clinical history and physical exam:
A 67 year old man was admitted due to silent ischemia. He had no chest pain, but positive noninvasive test such as thallium SPECT and treadmill test. He underwent ballooning at mid-LAD and bare-metal stenting( Wiktor) at proximal LCX in 1993 and 1996 , respectively. At seven years ago, He was attemted to open of total occlusion lesion of proximal LAD, but the attemption was failed. Because the thallium SPECT at one monthe ago revealed reversible perfusion defect of LAD territory, he underwent follow-up coronary angiography. The coronary angiogram showed diffuse ISR at previous stenting site (proximal LCX) and CTO at proximal LAD. So, he underwent stenting with 3.0 * 28mm and 4.0 * 23 mm Xience stent at proximal to distal LCX in the first and the CTO lesion was decided to do staged PCI. His coronary risk factor was only hyperlipidemia.

- Relevant test results prior to catheterization:
The treadmill test showed significant ST depression at stage 3 without symptom
The thallium SPECT revealed large sized mild-to- moderate perfusion defect in apical-mid anterior and mid-anteroseptal walls.
The 2D-echocardiogram showd normal LV systolic function(LVEF 68 %) without regional wall motion abnormality.

- Relevant catheterization findings:
Left coronary angiogram showed patent previous stents, proximal LAD total occlusion with TIMI 0 anterograde flow, and collateral flow grade II from RCA. (Figure 1, Figure 2).
Right coronary angiogram showed mild stenosis at proximal RCA.

- Procedural step:
A 7Fr XB 4 guiding catheter and 7Fr AL 1 guiding catheters were engaged in the left and right coronary artery through the bi-femoral approach, respectively. At first, the retrograde approach was attempted. The 0.014 inch Fielder FC wire was advanced via 1.8Fr finecross micro-guide catheter to RCA for regrograde approach (Figure 3). After failing the first guidewire passage, Fielder XT and Miracle 3 guidewire were used in turn regrogradely (Figure 4). And then, Fielder, Miracle 3g and Miracle 12g were used for antegrade approache to LAD (Figure 5). After successful wiring of LAD by antegradely, the lesion was dilated by 1.25 * 15mm Ryujin, 1.5 * 15mm Maverick balloon (Figure 6). Further ballooning of LAD was attempted after side-branch wiring using 0.014 inch Fielder wire and 3.5 * 33 mm, 2.5 * 33mm Cypher® stents were implanted, yielding a good final result (Figure 7, Figure 8).