J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 7 , N O . 1 6 , S U P P L S , 2 0 1 6 S159

Case Summary. We successfully treated a complex case whose syntaxscore was 40.5 with staged procedures. It is well known that collateralrecipient vessels should be treated earlier than donor vessels. How-ever, in the settings of treating multiple chronic total occlusions, weshould establish desirable situation to treat the most difficult lesion aseasily as possible. Therefore, we sometimes treat collateral donorvessels than recipient ones. Although thick guiding guiding cathetersare widely used to treat chronic total occlusions, narrow ones providegood performance even in the settings of retrograde procedures.

TCTAP C-065Challenging Re-attempting PCI to Proximal RCA-CTO Having Rich BridgeCollaterals

Masaki Tanabe11Dai-Ni Okamoto General Hospital, Japan

[CLINICAL INFORMATION]Patient initials or identifier number. SFRelevant clinical history and physical exam. An 84 y.o. male patient wassuffering from worseningdyspnea on effort. He had a chronic total oc-clusion (CTO) at the proximal rightcoronarywith rich bridge collaterals.He had been undertaken coronary intervention to the proximal

RCA-CTO two times in 2009 and 2012 in our cardiac catheterizationlaboratory, but without success.Relevant test results prior to catheterization. Prior CTO-PCIs to proximalRCA were performed in 2009 and 2012, however, without success.Various procedural steps had been alreadyattempted at these priorCTO-PCIs; parallel wire techniques, antegrade wiringwith IVUS guid-ance, and retrograde septal wire surfing via transseptally, andre-trograde approach via the epicardial collateral of the atrial branch oftheLCX.Relevant catheterization findings. CAG findings showed that RCA waschronically totallyoccluded, which had rich bridge collaterals. Theentry of the CTO was uncleardue to these collaterals. The maincontralateral collateral was found from theAC branch of the LCX via anAV groove to the RCA PL branch, but it was jailedby the bare metalstent which was implanted in case of emergent PCI due toonset ofmyocardial infarction over ten years before, and besides had tor-tuousmorphology in the at the middle part. The transseptal collateralsto the PD branchof the RCA were unclear whether there were con-necting to the PD branch of theRCA or not.[INTERVENTIONAL MANAGEMENT]Procedural step. The 3rd attempted PCI to the proximalRCA-CTO wasstarted by bilateral transfemoral approach after guide catheter-sinsertion using the 7Fr SPB 3.5 with side holes to the LCA and the 7FrSAL 1.0 with side holes to the RCA.Considering prior failed procedures, retrograde approach was

attempted from the beginning.

In the tip injection via the 3rd septal branch using the Car-avelmicrocatheter, it was found that the tiny (however, bending)transseptal collateral was connectedto the PD branch of the RCA.Careful wire manipulation using the Sion blackwith the Caravel sup-port was successfully negotiated and passed throughthistransseptalcollateral.After the long Corsair microcatheter advance to the CTO exit,

antegradewiringwas started, but it was difficult to penetrate the CTOentry using the UltimateBros.3 with the short Corsair microcatheter,eventually, it managed to be ableto penetrate the CTO entry using theMiracle 12g.Continuously, bilateral wiring within CTO segment was performed

using each of the Gaia 2nd, and then, each wire tip was able to cross-over. Consequently, classic reverse CART technique using 2.5mmballoon and IVUS guided reverse CARTwere performed. Finally, theretrograde Sion black was successfully passedthrough the CTOsegment.After wire externalization using the RG3, two BESs were implanted

to theproximal RCA-CTO.

S160 J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 7 , N O . 1 6 , S U P P L S , 2 0 1 6

Case Summary. Successful interventional revascularization was ach-ieved against challenging the 3rdattempted RCA-CTO with richbridging collaterals harmonizing utilization of a novel and classicprocedural steps with dedicated guidewires as well as dedicateddevices.

TCTAP C-066PCI for In-stent RCA CTO After Drug Coated Balloon

Masanori Teramura11Ichinoniya Nishi Hospital, Japan

[CLINICAL INFORMATION]Patient initials or identifier number. M.URelevant clinical history and physical exam. This patient is a 56 year-oldmale. This patient had a PCI for LAD-AMI on August 2010 and somePCIs for three vessels from 2010 to 2011. This patient admitted to our