A patient presented with angina due to a severe lesion in the mid LAD. The left main had been stented and had an ostial in-stent occlusion. The LAD was filling retrograde via a patent radial graft to the diagonal branch. The initial plan was to recanalize the left main CTO, followed by stenting of the mid LAD. Engagement of the left main with a guide was challenging. We tried antegrade crossing with a Gaia Next 3, but stopped after noticing staining of the aortic wall. We tried retrograde crossing using multiple guidewires (Gaia 2, Gaia 3, Gaia Next 2, Gaia Next 3, Hornet 14, Confianza Pro 12, Astato 20) but could not cross the distal cap, despite having extra support through a deeply seated Guideliner. We tried crossing through a dual lumen microcatheter but also failed to cross.
We decided to treat to mid LAD lesion via the radial graft despite extreme tortuosity. After multiple attempts we were able to deliver a 1.0x15 mm Sapphire Pro balloon to the mid LAD lesion, followed by a 2.0 mm Takeru balloon. The LAD lesion was undilatable, but eventually expanded after inflation at 27 atm with a non-compliant balloon. We attempted to deliver a 2.5x15 mm DES but failed to deliver it past the diagonal origin and the stent came off the balloon in the radial graft distal anastomosis. We advanced a 1.0 mm balloon through it but could not retrieve it. We failed to advance a 1.5 and a 2.0 mm balloon through the lost stent. Eventually we lost wire position. We rewired around the lost stent and crushed the stent with a balloon. We delivered the Guideliner past the distal SVG anastomosis (180° bend) distal to the lost stent. We were then able to deliver two DES in the mid LAD successfully treating the lesion. In the end a 3.5x18 mm DES was deployed across the lost stent.