A 46-year-old male presented with typical chest pain that persisted despite optimal medical therapy. The patient had type 2 diabetes, hypertension, dyslipidaemia, ex-smoker status, and a history of ACS (Anterior MI) 3 months ago without revascularization. Physical examination findings were within normal limits. 

The ECG showed a sinus rhythm with poor R-wave progression in the anterior lead. Blood test showed Cr 1.38 (eGFR 61 ml/min). The diagnostic angiography a month before the procedure (May 2025) demonstrated chronic total occlusion at proximal RCA, moderate lesion at LAD, and small calibre non-dominant LCx. 
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The diagnostic angiography at the index PCI procedure (June 2025) demonstrated chronic total occlusion at proximal RCA with an ambiguous course, mild lesion at LAD (previously interpreted as a moderate lesion), and a small-caliber non-dominant LCx. We decided to perform PCI CTO RCA with a retrograde approach due to the ambiguity of the RCA course. 
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The procedure began with double arterial access via the right femoral artery (XB 3.5/7F guide catheter) and the right radial artery (JR 3.5/6F guide catheter). A workhorse wire with a microcatheter was advanced into the septal branch, followed by contrast injection, confirming a retrograde pathway to the RCA. Septal surfing was performed with a Suoh 03 wire (soft, 0.3 gr tip load), successfully reaching the distal and mid RCA. The wire exchange to an Anyreach P 1.0 wire (polymer jacketed, 1 gr tip load) and attempted to cross the distal CTO cap. Upon reaching the CTO body, the wire could not advance through the proximal cap. Escalation to an Anyreach P 6.0 wire (polymer jacketed, 6 gr tip load) successfully penetrated the proximal cap but failed to enter the guide catheter, likely due to subintimal positioning. We de-escalated to an Anyreach P 1.0 wire and successfully snared the wire into the guide catheter after several attempts. The microcatheter was advanced into the guide catheter, and the tip-in technique was successfully performed with a workhorse wire, allowing antegrade wire passage into the distal RCA. Pre-dilatation was performed using semi-compliant balloons (1.5×15 mm and 2.0×15 mm) followed by a 2.75×15 mm non-compliant scoring balloon from distal to ostial RCA. IVUS was used to assess vessel morphology and size. Three drug-eluting stents (2.75×38 mm, 3.5×20 mm, and 4.0×26 mm) were implanted from distal to ostial RCA, achieving a satisfactory final angiographic result.
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This case highlights the successful navigation of a complex proximal RCA CTO using advanced retrograde PCI techniques. Combining dual arterial access, septal surfing, wire escalation, and the tip-in technique, the team overcame anatomical challenges and an ambiguous vessel course. With IVUS guidance and careful balloon pre-dilatation, optimal stent placement was achieved, resulting in excellent revascularization. This case underscores the power of cutting-edge interventional strategies to tackle difficult CTOs and enhance patient outcomes.