First successful implementation of subintimal transcatheter withdrawal technique in intravascular ultrasound–guided tip detection antegrade dissection and reentry: a case report

BACKGROUND: Antegrade dissection and reentry (ADR) is an effective technique for wire passage in chronic total occlusion (CTO), and in recent years, the effectiveness of intravascular ultrasound (IVUS)–guided tip detection (TD)-ADR has been reported. However, the expansion of the subintimal space serves as a significant obstacle to the success of ADR, posing a limitation to the procedure. CASE SUMMARY: We present the first case of using IVUS-guided TD-ADR with the subintimal transcatheter withdrawal (STRAW) technique. The patient was a 68-year-old Asian female with effort angina pectoris and a CTO in the middle section of the right coronary artery (RCA). Two previous attempts at percutaneous coronary intervention (PCI) for the RCA at another hospital were unsuccessful. During the third attempt PCI, the antegrade wire migrated into the subintimal space. To address this, we performed IVUS-guided TD-ADR using the Conquest Pro 12 Sharpened Tip (CP12ST; Asahi Intecc, Aichi, Japan) wire. However, due to the expansion of the subintimal space, we were unable to puncture the true lumen. To reduce the subintimal space, we employed the STRAW technique, which allowed successful puncture of the true lumen using the CP12ST wire. Finally, stenting was performed, resulting in satisfactory antegrade blood flow. DISCUSSION: Intravascular ultrasound–guided TD provides accurate guidance for puncturing in ADR procedures, but the expansion of the subintimal space remains a significant challenge. The STRAW technique offers a solution by reducing the subintimal space and enabling successful puncture of the true lumen during IVUS-guided TD-ADR.