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A patient with prior CABG had recurrent failure of a radial graft to the LAD and was referred for attempting PCI of the native LAD CTO. The LAD had a flush ostial occlusion, length of approximately 20 mm and good quality distal vessel filling via the radial graft to the LAD. A retrograde Sion black was advanced to the distal cap, followed by advancing a knuckled Gladius Mongo wire that seemed to enter a side branch. The wire was redirected and eventually advanced extraplaque next to the left main. Using the retrograde wire as marker antegrade crossing was attempted with a Gaia Next 2 wire without success. The Gladius Mongo wire eventually went into the circumflex, where it was snared with a 2-4 mm EnSnare. The retrograde microcatheter would not cross the CTO, but eventually a FineCross M3 crossed into the antegrade guide catheter, followed by externalization of an R350 wire. A dissection was noted in the circumflex, hence DK crush was used in the left main bifurcation, successfully covering the dissection. A perforation was then noted in the proximal LAD that was successfully treated with a PK Papyrus stent. The radial-LAD graft was coiled with a nice final result.