Tip detection-antegrade dissection and re-entry (TD-ADR) with integrated fluoroscopic and intravascular ultrasound images in chronic total occlusion: first case report of integrated TD-ADR technique

Author:

Tadano Yutaka1ORCID,Kuramitsu Shoichi1,Sugie Takuro1,Kanno Daitaro1,Fujita Tsutomu1ORCID

Affiliation:

1. Department of Cardiovascular Medicine, Sapporo Cardio Vascular Clinic, Sapporo Heart Center , North 49, East 16, 8-1, Higashi Ward, 007-0849, Sapporo , Japan

Abstract

Abstract Background Tip detection-antegrade dissection and re-entry (TD-ADR) technique allows operators to accurately observe both guidewire tip direction and a true lumen in chronic total occlusion (CTO) lesions, while the torque direction of the guidewire on IVUS images does not invariably correspond to that on fluoroscopic images. Case summary A 41-year-old man with hypertension who smokes presented with sudden onset of dyspnoea, acute heart failure, and ischaemic findings on electrocardiogram; we performed percutaneous coronary intervention (PCI) for a sub-totally occluded mid-left anterior descending artery lesion. All antegrade wiring attempts failed to enter the distal true lumen followed by subintimal tracking and re-entry technique. Since the lesion re-occluded the next day, we treated the lesion using a novel TD-ADR technique, termed the ‘integrated TD-ADR’, because of no interventional retrograde channel. This method integrates fluoroscopic and intravascular ultrasound (IVUS) images, ensuring congruence in the torque direction of the guidewire across both modalities and enabling vertical puncture of the stiff guidewire from the extraplaque space to the distal true lumen quickly and precisely. Final angiography showed good results. Five months later, coronary angiography showed that the lesion remained open. Discussion The integrated TD-ADR technique merges fluoroscopic and IVUS images, allowing operators to torque the guidewire in the same direction on both images. This approach might be more user-friendly than the original technique and has the potential to enhance the success rate of PCI in complex CTO cases. However, further investigations are warranted to address the clinical feasibility and applicability of this technique.

Publisher

Oxford University Press (OUP)

Reference8 articles.

1. Recanalisation of coronary chronic total occlusions;Di Mario;EuroIntervention,2022

2. Tip detection method using the new IVUS facilitates the 3-dimensional wiring technique for CTO intervention;Okamura;JACC Cardiovasc Interv,2020

3. Tip detection-antegrade dissection and reentry using intravascular ultrasound in chronic total occlusion intervention: first human case report;Suzuki;Eur Heart J Case Rep,2022

4. Tip detection-antegrade dissection and re-entry with new puncture wire in CTO intervention: revolution through 3D-wiring;Tanaka;JACC Asia,2024

5. Intravascular ultrasound-guided dissection recanalization in a patient with ST-segment elevation myocardial infarction: a case report;Sangen;Eur Heart J Case Rep,2023

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