- Relevant clinical history and physical exam:
A 53 years old man was referred to cardiology for evaluation of abnormal finding of pre-operative work-up (hepatocellular carcinoma). Thallium SPECT showed partially reversible moderately decreased perfusion in LAD territory. He didn’t have any symptom. Coronary angiography (CAG) showed total occlusion of LAD ostium. (Figure 1,2) So, he received Transcatheter Arterial Chemoembolization (TACE). The distal LAD was well filled through the rich collateral channels of the RCA. So, he received Transcatheter Arterial Chemoembolization (TACE). His risk factor was only smoking. The creatinine value was 0.9 mg/dL (estimated GFR = 90).

- Relevant test results prior to catheterization:
The transthoracic echocardiography showed normal finding (ejection fraction = 60%). Thallium SPECT showed partially reversible moderately decreased perfusion in LAD territory.

- Relevant catheterization findings:
The target lesion was a CTO lesion in the proximal LAD. The distal LAD was well filled through the rich collateral channels of the RCA. (Figure 1, Figure 2).

- Procudural step:
A 7Fr XB-3.5 guiding catheter was engaged in the left and a 5Fr JR -4.0 guiding catheter in the right coronary artery through the bi-femoral approach, respectively. At first, the antetrograde approach with the combination of an Fielder FC 0.014 inch guide-wire and a Progreat® 2.0 Fr -150cm microcatheter was attempted. (Figure 3) However, the occluded segment was so hard. So, by exchanging the guide-wire to Miracle 3g & Miracle 12g sequentially, successful crossing to the true lumen proximal to the CTO lesion was achieved. (Figure 4, Figure 5) At this point, a Ryujin® 1.25-mm OTW balloon was introduced and inflated in the proximal part of the CTO lesion to create a large lumen. (Figure 6) Following this balloon inflation, predilation with Sprinter 2.0 * 20mm balloon was performed. (Figure 7) And then, we deployed two bare-metal stents (MULTI-LINK VISION 3.5 * 28 mm at LAD, DRIVER 3.0 *24mm, sequentially). (Figure 8, Figure 9) Final angiogram showed successful revascularization at LAD CTO lesion. (Figure 10, Figure 11) We used only 360 cc amount of contrast (Visipaque).