A 67-year-old male presented with worsening effort angina and dyspnoea on exertion since past 3 month. Comorbidities includes hypertension, dyslipidaemia, and ex-smoker. His 12-lead ECG showed Sinus Rhythm with pathological Q wave at V1-V3. At presentation physical examination including cardiovascular examination was unremarkable.

Echocardiography showed  normal cardiac chamber size and  normal Ejection Fraction. No regional wall motion abnormalities was seen and all of cardiac valves were normal. His chest-ray and blood test laboratories finding were within normal range.

Left Main Coronary Artery: NormalLeft Anterior Descending artery: Total occlusion at the ostium with blunt stump. Distal part receives blood flow from collateral circulation (Rentrop III). Calcified at proximal segmentLeft Circumflex artery: Tubular stenosis 80% at the proximal segmentRight coronary artery : Discrete stenosis 60% at DistalThe Heart Surgery Conference decided to perform PCI.

We performed PCI with dual injection strategy, guide catheter XB 3.5/8F on right femoral and JR 3.5/6F on right radial. IVUS guided was used to determine entry cap of osteal LAD. CTO was successfully crossed using wire Asahi Gaia Next III with microcatheter. Predilatation performed using semi compliant balloon 1.0 x 10 mm escalated to 2.5 x 15 mm. IVUS of LAD showed severe calcified plaque, calcified nodule and napkin ring (IVUS Calcium Score 3). We tried Scoreflex NC ballon 2.5 x 15 mm to modified the plaque, but it wasn’t fully expanded (24 atm). Angiography showed TIMI 3 Flow LAD with multiple non flow limiting dissection. We decided to stop PCI at LAD and proceeded PCI at LCx with DES 3.0 x 38 mm. Two months later, we reattempted PCI with Rotational Atherectomy. LCA was cannulated with XB 3.5/7F, angiography showed severe calcified LAD with no visible dissection. Rotational atherectomy was performed with a 1.5 mm burr up to 200000 rpm. Post-atherectomy IVUS showed calcium crack, distal reference lumen diameter 3.14-3.55 mm and osteal LAD EEM 4.46-4.63 mm. Pre-dilatation was performed using scoreflex NC 2.5 x 15 mm and 3.5 x 15 mm. Proximal-mid LAD was stented with DES 3.0 x 28 mm (16 atm), and osteal LAD using DES 3.5 x 28 mm (16 atm). We optimized stent expansion with NC balloon 3.0 x 15 mm (20 atm) mid LAD and NC 4.0 x 15 mm (20 atm) osteal-proximal LAD. Final IVUS showed stent well apposed and well expanded with no dissection (MSA distal 6.64 mm², Proximal 10.79mm²).

When a procedure cannot be performed as planned, we need to step backward, reanalyse, and always be prepared with plan B. In this case, we experienced the challenge of CTO with ambiguous cap with unexpected severe calcified lesion. When the CTO was successfully crossed yet Scoring NC balloon could not be fully inflated and dissections were seen, we decided to stop the procedure. We changed the strategies and reattempt PCI using rotational atherectomy for  optimal plaque preparation after the dissections were healed.