After fixing the perforation, we reattempted the retrograde approach this time successful.

Besides the steps described in the slide , we also re-advanced a knuckle wire in the retrograde MC to provide stability due to tendency of jumping back into the epicardial( tortuosity).

Retrograde MC was not advancing due to severe tortuosity, obviously failing to reach the RCA ostium and preventing externalisation with RG3. Therefore we decided to use the "tip -in" technique (catching with the tip of the retrograde wire ,the lumen of the antegrade MC)

With antegrade contrast injection we still see extravasation of contrast despite MC plugging the perforation.

Wiring of epicardial went easy , here after followed with a Caravel MC. The MC couldn't advance further due to severe tortuosity , same also for earlier used wires. We therefore used Gaia 2 wire (to create minimum dissection) +knuckle wire to safely advance up to the ostium.

We decided to use the epicardial collateral to retrogradely create a neo-ostium in order to seal the perforation.

We tried to follow the wire with the MC but it became stuck in the calcium. We retracted the wire and attempted the #Carlino technique and discovered that contrast was in the pericardium (we didn't save this run, sorry guys).

At this point we already attempted a retrograde approach which was unsuccessful due to septal tortuosity. We rapidly shifted to the antegrade approach and the wire progressed quite easily in what we believed WAS the structure of the RCA but in fact we were in the pericardium.

Initial angio with ostial RCA CTO, epicardial collateral up to mid segment RCA. 2nd occlusion in mid distal segment. Small septal collaterals perfuse the distal RCA. @RinfretStephane #cardiotwitter