Retrograde percutaneous coronary intervention in a calcified and dissected left anterior descending artery using single catheter - To lose the patience is to lose the battle.

Percutaneous coronary intervention (PCI) after iatrogenic coronary dissection in a heavily calcified vessel is technically challenging and a retrograde approach helps in that scenario. "Reverse rota wiring" shortens the procedure time in retrograde PCI whenever rotational atherectomy is planned. A 70-year-old male patient with previous PCI to diagonal and left circumflex arteries and attempted PCI to left anterior descending (LAD) and right coronary arteries, presented with exertional angina. After documenting ischemia, PCI to LAD was scheduled. After failed initial antegrade attempts, retrograde wiring through the diagonal was done. Then reverse rota wiring and rotational atherectomy (RA) to LAD using 1.25 mm burr was done. Since the 1.25 mm rota burr was entrapped, the entire system was manually pulled back. Repeat retrograde wiring and RA using 1.5 burr was done since the intravascular ultrasound showed >270° calcium. After multiple balloon dilatations, stenting was done using two drug-eluting stents. Coronary perforation with cardiac tamponade occurred after stenting. After pericardiocentesis, perforation was sealed with a guidezilla-II assisted covered stent implantation and final thrombolysis in myocardial infarction (TIMI) 3 flow was achieved. The patient remained symptom-free at one-year follow-up. Operator skills and perseverance are essential for good outcome in complex PCIs. Learning objectives: 1.Retrograde percutaneous coronary intervention is useful in iatrogenic coronary dissection, when antegrade attempts to enter the true lumen fail.2.'Reverse rota wiring' is an alternative method to do rotational atherectomy after retrograde wire crossing. It shortens the procedure time and it is useful in heavily calcified lesions where balloon uncrossability is anticipated.