This 50 years old hypertensive male patient with previous Acute Coronary Syndrome 3 years back, presented with worsening angina on exertion NYHA class  III for last 3 months. 

Echocardiography revealed LAD territory hypokinesia and LVEF of 45 %. 

Coronary angiography done outside showed normal LM, ostial LAD cut off with retrograde filling from RCA via Grade 2 collaterals, ostial Lcx 90% stenosis (D1,D2) , large normal OM1, small and diffusely diseased OM2 and OM3, dominant RCA showing mid plaque and distal 50 % stenosis (D3).

8F JL coronary guide catheter was taken from the right femoral artery and a TIG diagnostic catheter was taken from right radial artery and bilateral angiograms were taken. A floppy guide wire was placed in Lcx and ostial Lcx lesion was predicated with a 2*12 mm non compliant balloon. An IVUS catheter was placed      over Lcx wire and under IVUS guidance a Gaia 3 coronary wire (Asahi, Japan) over a micro catheter was used to probe the ambiguous osmium of LAD (T1).    Using contralateral injection in RCA, the Gaia 3 wire was seen extending into the false lumen in distal LAD. A Conquest Pro 12 (Asahi, Japan) was then taken    over a micro catheter using a parallel wire strategy and successfully negotiated in distal true lumen of LAD (T2). After pre dilatation of LAD, Conquest Pro wire  was exchanged for a floppy guide wire over a micro-catheter. IVUS run was then taken from LAD to LM and LCx to LM for vessel sizing. In view of the               discrepancy in size of LAD/LCx and LM, 2 coronary stents were placed in a V technique from LM to LAD and LM to LCx and deployed. The stents were then     post dilated and final kissing balloon inflation was done and the results were optimised by IVUS. Final cine showed well expanded LM LAD/LCx stents with TIMI 3 flow (T3).

This was a challenging case of long segment ostial LAD CTO with ambiguous stump.  IVUS helps to guide the proximal cap puncture in ostium LAD which cannot be seen on angiogram.  Ostium LCx was diseased which was predicated with a semi-compliant balloon to help place the IVUS catheter. Parallel wire technique is a good technique when the first wire continues in the false lumen distally. The second wire should be stiffer and more angulated  than the first wire which helps in entering the true lumen distally.  V technique for LM bifurcation is a good technique when there is size discrepancy between Lad/LCx and LM.