case_images: PMC9314161_01
case_images: (a-k) Selective right coronary artery injection shows well-developed collateral vessels, which fill the left anterior descending artery (LAD) retrogradely (a). Selective left main injection shows a totally cut LAD at the midpart (at the trifurcation point) with an ambiguous cap and a lengthy occluded segment, with a good runoff (b). A large proximal septal branch fills the LAD antegradely. Hence, with the aid of a SUOH 03 wire (ASAHI Intecc Medical) and a Caravel 150 cm microcatheter (ASAHI Intecc Medical), septal surfing is performed (c). Once the wire reaches the distal cap, the microcatheter is advanced over it (d). Thereafter, with a Gaia second wire (ASAHI Intecc Medical), several attempts are made to puncture the distal cap but to no avail. Subsequently, with a Gladius wire (ASAHI Intecc Medical), the distal cap is crossed, the wire is tipped into the guide catheter, and the same microcatheter is passed over it (e). In this stage, a SION blue wire (ASAHI Intecc Medical) is advanced antegradely toward the retrograde microcatheter ("reverse tip-in"), creating a loop between the LAD and the septal branch (f). Afterward, the microcatheter is retracted, and predilation and LAD preparation are done antegradely (g). The wire is positioned antegrade to the diagonal branch at the site of the trifurcation (h). Under the guidance of a dual-lumen SASUKE microcatheter (ASAHI Intecc Medical) over the SION blue wire, the Gaia second wire is advanced toward the LAD (i). The LAD is then predilated, and stenting is performed, yielding good final results (j, k).
case_images: CRIC2022-2952898.001.jpg
case_images: PMC9314161_01_CRIC2022-2952898.001.jpg
case_images: fig1
case_images: The procedure demonstrated total occlusion in the midpart of the left anterior descending artery (LAD) with retrograde and ipsilateral interventional collateral vessels (Rentrop grade III) (Figures 1(a) and 1(b)). As shown in Figure 1(b), there was one large septal branch at the proximal segment of the LAD with one good collateral vessel to the midportion of the LAD. Once the distal cap was accessed (Figure 1(d)), the wire was substituted with a Gaia second wire (ASAHI Intecc Medical) to puncture the distal cap but to no avail. Intecc Medical), the occluded segment was crossed, and the microcatheter was passed to the proximal part of the LAD over the Gladius wire and then into the same guiding catheter. In this step, with a workhorse SION blue wire (ASAHI Intecc Medical) from the guiding catheter, the wire was inserted into the tip of the microcatheter (the "reverse tip-in" technique) before it was passed distal to the occluded segment (Figures 1(e) and 1(f)). Afterward, the microcatheter was pulled back, and the wire was positioned antegrade to the diagonal branch at the site of the trifurcation (Figure 1(g)). Next, under the guidance of a dual-lumen SASUKE microcatheter (ASAHI Intecc Medical) over the SION blue wire, the Gaia second wire was advanced toward the LAD (Figure 1(i)). Thereafter, a 3 x 38 drug-eluting stent was implanted, and it was postdilated with a 3.5 noncompliant balloon, conferring good final results (Figures 1(j) and 1(k)).