Successful interventional revascularization utilizing hybrid procedural steps of rotational atherectomy and retrograde approach via an ipsilateral collateral

Here, we report a case of successful interventional revascularization of the left anterior descending artery (LAD) in two heavy calcified chronic total occlusion (CTO) lesions, which were uncrossable utilizing hybrid procedural steps of local rotational atherectomy and a retrograde approach by reverse controlled antegrade and retrograde tracking (CART) technique via an ipsilateral intraseptal collateral. A-76-year-old man that had undergone previous coronary artery bypass surgery was admitted for ischemic heart failure. Coronary angiography showed that the left internal thoracic artery graft that was anastomosed to the first diagonal branch was patent. However, his native LAD had two CTOs as if the open vessel had sandwiched them. Moreover, there were no interventional collaterals. The antegrade guidewire was successfully passed through both CTOs. However, devices were uncrossable at the entry of the distal LAD-CTO. After stent deployment at the proximal CTO, local rotational atherectomy with a 1.5 mm burr was performed as plaque modification from the protruding calcified plaque at the bifurcation of the first septal branch to the distal CTO entry for the following procedure, although the dedicated guidewire was unable to pass completely through the distal CTO segment. Staged PCI to the distal LAD-CTO was performed using a retrograde approach via an ipsilateral intraseptal collateral, which had grown due to recanalization of the proximal LAD-CTO. Due to plaque modification by rotablation at the first attempt, successful interventional revascularization to the distal LAD-CTO was accomplished using the reverse CART technique.