The diagnostic coronary angiogram revealed total occlusion at proximal RCA, mid LAD and proximal LCX with grade III collateral flow from Diagonal to LAD, LAD to RCA. (Figure 1, Figure 2, Figure 3)

We decided to PCI because the patient refused CABG. We had a plan to perform PCI by retrograde approach. After engagement of an 8 French EBU guiding catheter to the left main ostium, we inserted Fielder wire with a micro-catheter into the diagonal branch for the ipsilateral retrograde approach (Figure 4). Then, Conquest-pro 12 punctured the proximal cap and entered the true lumen of LAD and dilated the proximal cap with the one point two five(1.25) balloon. After pre-dilatation with two point zero(2.0) and two point five(2.5) balloon sequentially (Figure 5), conventional wire crossed the LAD antegradely. Endeavor stents were deployed at the lesion by crushing technique (Figure 6). Final left angiogram showed good result (Figure 7). Then we performed RCA PCI by contra-lateral retrograde approach. The Fielder wire with a micro-catheter got to the distal portion of RCA lesion through the LAD septal channel (Figure 8). Fortunately, the Conquest-pro 12 punctured the proximal cap and sequential pre-dilatation was done (Figure 9). After multiple pre-dilatation, we could insert Fielder wire antegradely. We dilated the lesion with two point five(2.5) and three point zero(3.0) balloon. Three Endeavor stents were deployed at the long lesion. But we could not dilate fully at the calcified proximal RCA lesion with a non-compliant balloon (Figure 10). Final angiogram showed successful revascularization at RCA CTO lesion (Figure 11).
8-months later after PCI, follow up coronary angiography revealed total occlusion of previous RCA lesion (Figure 12, Figure 13). Fortunately, the Conquest pro 12 crossed the lesion. But the balloon delivery was failed due to un-dilated calcified proximal RCA lesion. So, the Rotablation was performed and sequential high pressure balloon dilatation was done (Figure 14, Figure 15). Final angiogram was not so bad (Figure 16).
7-months later after second PCI, follow-up coronary angiography showed total occlusion at the RCA lesion again (Figure 17). Patient had not complained of chest discomfort. We chose the LCX CTO PCI.
The Venture catheter with curved configuration was used for strong support and then the Conquest pro 12 crossed the CTO lesion. But it is not to easy to cross the distal occlusion lesion. Double lumen catheter with Miracle 3 was advanced along the Conquest 12 and could get to the distal portion (Figure 18). After stenting at the distal LCX, the balloon and stent delivery was attempted to treat the proximal LCX lesion, however, that was failed due to un-dilated calcified proximal LCX lesion. Therefore the rotablation was performed (Figure 19). But indentation was still showed (Figure 20). IVUS showed concentric luminal calcification with about two point zero(2.0) lumen diameter (Figure 21) therefore we decided to treat the calcified lesion by two point zero(2.0) Rotablation again. Then, we could dilate the culprit site with a high pressure balloon and deploy stent at the proximal LCX lesion (Figure 22). Final angiogram and IVUS image showed good result (Figure 23, Figure 24).