74 year-old man was admitted for 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 echocardiography and ECG showed non-specific findings. The diagnostic coronary angiography was done and showed diffuse stenosis in mid-LAD with chronic total occlusion in RCA. We performed stent (PROMUS 3.5*28mm) deployment in mLAD about 15 days ago. A thallium spect showed reversible perfusion defect in RCA territory. So he admitted to recanalize the occluded coronary artery lesion in RCA.

1. A right coronary angiogram showed TIMI 0 flow at mid portion of RCA with collateral from LCX & LAD ( movie 1).
2. A left coronary angiogram showed patent previous deployed stent in mLAD lesion. ( movie 2)

Firstly, left coronary was cannulated with a 7 Fr XB 4.0 guiding catheter and right coronary was inserted with AL1 7 Fr SH guiding catheter. Initially, by using a Finecross® 0.014 inch 1.8 Fr -130cm micro catheter, 0.014 inch Fielder XT wire was tried into septal branch across the previously deployed stent strut. After crossing the stent strut, contrast injection via micro catheter showed no septal connection into RCA branch. ( movie 3) So, we decided to negotiate via epicardial collateral from LCX to RCA (PL branch). (Figure 1, Figure 2, Figure 3) Using a Finecross®, 0.014 inch Fielder FC wire was advanced into tortuous epicardial collateral. And then Corsair 0.014inch 1.8 Fr -150cm channel dilator was inserted. (Figure 4, Figure 5, Figure 6) The wire was changed into 0.014 inch Whisper wire & miracle 3g, consecutively. (Figure 7) We approached antegradely with Finecross with Fielder FC wire.(Figure 8) We performed several antegrade balloon dilatation to create a subintimal space, with Ryujin 1.25*15, AvitaNM 2.5*15, Ryujin 2.5*15 and Voyager 3.5*15mm balloon, sequentially. So, that was “Reverse CART technique”. (Figure 9, Figure 10) The retrograde wire was advanced into the antegrade guiding catheter (Figure 11) and then was trapped there by balloon (Ryujin 2.5*15) at 10 atm, so that a Corsair could be followed into guiding catheter. Then the wire was changed to a 300cm Fielder FC wire. The retrograde wire was externalized into antegrade sheath. (Figure 12) More predilation was performed using this reversed 300cm wire. The sequential four Xience-V stent (2.5*28 + 3.0*28+3.5*28+3.5*15) were deployed from distal RCA to proximal RCA. The final angiogram showed well positioned and expanded stent with good distal run-off flow. ( movie 4)