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IntroductionThe success rate of guide wire crossing in coronary intervention to chronic total occlusions has been increasing with the improvement in guide wire performance and the widespread use of retrograde techniques. However, device delivery failure remains a main reason for technical failure [1], and the presence of heavy calcium masses is one factor preventing devices from crossing through the occlusion.We herein report a case of a heavily calcified coronary occlusion lesion in the left anterior descending artery that was successfully treated with the retrograde balloon crossing technique. Case reportA 64-year-old man with intermittent claudication was admitted to our hospital. His risk factors were diabetes, hypertension, hyperlipidemia, and a history of smoking. Angiograms showed severe stenosis in the right femoral artery and the left popliteal and anterior tibial arteries, as well as total occlusion of the proximal left anterior descending coronary artery with an epicardial collateral channel from the right coronary artery ( Figs. 1 and 2A ). After endarterectomy for the right femoral artery and balloon angioplasty for the left popliteal and anterior tibial arteries, we evaluated his myocardial ischemia via cardiac scintigraphy. Although the left ventricular systolic function was preserved and he had no complaints of chest pain, a large perfusion defect with redistribution in the anterior wall was demonstrated, so we tried to open the left anterior descending artery. However, severe coronary calcification that had been noted on coronary computed tomography angiography (Fig. 2G) prevented the guidewire from crossing through the occlusion antegradely. We therefore tried to treat the lesion via the retrograde approach in our second attempt at coronary intervention. Using an 8-Fr extra back-up-type guide catheter (Luncher EBU3.5 SH; Medtronic Vascular, Santa Rosa, CA, USA) via the left femoral artery, we started antegrade crossing with a gradual increase in the wire stiffness; however, we failed to cross the lesion even with a A B S T R A C TWe herein report a case of percutaneous coronary intervention to a heavily calcified chronic total occlusion in the left anterior descending artery. Although we successfully performed retrograde wire crossing and wire externalization, we were unable to deliver small-sized balloon catheters in the lesion antegradely, even with strong back-up of wire externalization because of the heavy calcium mass. However, a balloon catheter was easily crossed retrogradely, and the lesion was successfully treated. Thus, retrograde balloon crossing might be a way to overcome device delivery failure in calcified lesions.

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