A 40-year-old gentleman, non-smoker with underlying Diabetes mellitus and Dyslipidaemia, was admitted for recurrent Unstable angina in late 2023. General examination showed HR 64 bpm, sinus rhythm, BP 118/64mmHg; lungs and CVS unremarkable. ECG on arrival showed sinus rhythm with no ST segment changes. He was admitted for Acute coronary syndrome treatment with DAPT and anti-coagulation. 

Troponin I was not raised. Otherwise, other blood investigations are unremarkable. CXR showed clear lung fields with no cardiomegaly. Echocardiography showed LVEF 60-65% with no RWMA. Coronary angiography showed mild distal LM disease with mild proximal LAD disease, supplying Rentrop Grade 3 collaterals to PDA and proximal 30-50% disease of main diagonal. Proximal subtotal occlusion and distal CTO of non-dominant LCx and dominant RCA with diffuse proximal to mid 80-90% disease with distal CTO.
LAD.mp4
LCx.mp4
RCA.mp4

Right 6Fr trans-radial sheath used for contralateral access, LAD engaged with 6Fr EBU 3.5 guide catheter and a BMW guidewire passed into distal LAD. Right 7Fr trans-femoral sheath inserted and RCA engaged with 7Fr AL 0.75 guide catheter and bilateral contrast injection performed. Sion Blue gw with CorsairPro microcatheter support, passed into proximal-RCA and escalated to FielderXT-A, unable to cross proximal CTO, hence switched back to SionBlue and left in-situ. Switched to retrograde approach.
LAO.avi
RAO.avi
Antegrade Approach.avi

SionBlue with Caravel microcatheter advanced into midRCA,septal-surfing with Suoh03 through septo-epicardial collaterals. Caravel track through septal into PDA,escalated FielderXT-A,FielderXT-R,Pilot150, unable to puncture distal CTO cap.XT-R advanced into PDA and subintimal into proximalRCA via Knuckle wire technique. Antegrade GuidePlusII guide-extender (GE) to deliver NC2.0x15mm into proximalRCA,predilated proximalRCA. Proximal-midRCA predilated with NC3.0x15mm to assist retrograde entry with ReverseCART. Retrograde XT-R entered true lumen into antegrade GE,unable to cross retrograde Caravel. Antegrade CorsairPro with SionBlue waiting within GE,retrograde XT-R positioned into antegrade microcatheter within antegrade GE via Tip-in technique. Antegrade Corsair advanced over retrograde XT-R till distal to CTO while backingout retrograde Caravel. Antegrade Corsair advanced till distalPDA,SionBlue advanced into distalPDA,retrograde XT-R redrawn.Antegrade Corsair removed. Distal-midRCA predilated with NC2.0x15. Attempted wiring PLV with XT-A using Sidecar technique,unsuccessful d/t retroflexedPLV. ProximalPDA predilated with SC2.0x20. DistalRCA-proximalPDA stented with DES2.5x38mm, postdilated NC3.0x15. IVUS performed. Mid-distalRCA stented with DES3.0x38mm, ostial-proximalRCA with DES3.5x38mm,post-dilated NC3.5x15mm. OstialRCA POT NC4.5x8. PCI LCx,Suoh03 with Corsair advanced into distalLCx,predilated distal-proximalLCx with NC2.0x15 & Scoring2.5x15mm,treated with DCB2.5x40
Tip in technique.mp4
RCA final shot.mp4
LCx final shot.mp4

Tip-in or Rendezvous techniques can be used upfront rather than when Retrograde wire externalization (RWE) technique is unfeasible/undesirable after successful retrograde guidewire crossing. Sidecar technique with guidewire co-transporter represents a simple and inexpensive alternative solution to deliver a second guidewire distally once CTO is crossed, in suitable lesions. Use of DCBs in small vessel size, avoiding use of stents.