63 An old female patient presented with unstable angina for  6 months, k/c/o HTN, TYPE II DM, 2DECHO S/O LVEF 45% WITH INFERIOR WALL HYPOKINESIA WITH PRESERVED WALL THICKNESS., CAG S/O TVD WITH RCA CTO 

2D ECHO S/O INFERIOR WALL HYPOKINESIA , LVEF45% WITH PRESERVED WALL THICKNESS.

CAG S/O TRIPLE VESSEL DISEASE, WITH RCA CTO FILLING RETROGATELY. ADVICE CABG BUT PATIENT IS NOT WILLING FOR CABG 

PTCA with Retrograde Rendezvous for Chronic Total Occlusion (CTO)An individual with a stubborn Chronic Total Occlusion (CTO) in the RCA (Right Coronary Artery) initially underwent a failed antegrade percutaneous transluminal coronary angioplasty (PTCA). Despite multiple wire attempts (e.g., CROSSIT 200, PILOT 150), the procedure was aborted due to a spiral dissection.A month later, a second attempt was made using a more advanced approach. The steps were as follows:Retrograde Access: The interventional team chose a retrograde approach, navigating a wire and microcatheter through collateral vessels to reach the RCA distal to the blockage.Antegrade Access: Simultaneously, an antegrade wire was advanced from the proximal end of the RCA to the blockage site.Rendezvous: The retrograde and antegrade wires were "kissed" at the site of the CTO. This crucial step, known as the rendezvous technique, allowed the antegrade wire to be precisely guided.Final Crossing: The antegrade wire was then advanced through the antegrade microcatheter, alongside the retrograde wire, finally penetrating the true lumen distal to the CTO.Revascularisation: Once the path was clear, the retrograde wire was removed. The RCA was then successfully revascularized with balloon dilations and the deployment of two stents.

RETROGRADE WITH GRADE 1 OR 2 COLLATERALLS IS CHALLENGINGWhen a microcatheter can not cross RETROGRADELY INTO THE RECIPIENT VESSEL, THERE IS DIFFICULTY TO CROSS the CTO SEGMENTHYBRID APPROACH AND TECHNIQUES LIKE RENDEVOUZ ARE VERY EFFECTIVE