Right coronary artery was engaged a 7 Fr AL1 guiding catheter and left coronary artery was positioned with a 7 Fr XB 3.5 guiding catheter through the bi-femoral approach. At first, we tried anterograde approach using Fielder XT-A, Gaia second with Corsair 135cm catheter, but it was not successful. ( Movie 3) After that, we tried retrograde approach using SUOH, Gaia second, Fielder XT-R wire with Corsair 150cm catheter. ( Movie 4) After careful subintimal tracking of the retrograde guidewire directed to the tip of antegrade guidewire, the subintimal space was dilated with PCI balloons (IKAZUCHI 2.5 x 15mm and TREK 3.5 x 15mm) in antegrade direction. ( Movie 5) After the true lumen of the anterograde was confirmed by IVUS, a stent (Xience Alpine 4.0 x 28 mm) was implanted to secure the lumen for the reverse CART. (Figure 1) Finally, successful advancement of retrograde guidewire into the space dilated with drug-eluting stent and the retrograde wire was externalized into RCA guiding catheter. (Figure 2) Thereafter, the CTO lesion was treated with usual IVUS-guided coronary intervention methods. Four Xience Alpine (2.75 x 28, 3.0 x 38, 4.0 x 38mm) stent was sequentially deployed from distal to proximal with some overlap. (Figure 3) The final angiogram showed well positioned and expanded stent with good distal run-off flow. ( Movie 6, Movie 7) We attached final IVUS images. ( Movie 8)
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