Synergistic Application of HydroDynamic contrast Recanalization and IVUS‐Guided Tip Detection‐Antegrade Dissection and Re‐Entry in CTO PCI

Antegrade percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) remains technically challenging. HydroDynamic contrast Recanalization (HDR) is a novel technique involving low-pressure, low-volume intraplaque contrast injection immediately distal to the proximal cap, with the goal of modulating plaque architecture and facilitating a polymer-jacketed guidewire advancement toward the distal true lumen. Intravascular ultrasound (IVUS) is useful in two HDR-related scenarios: first, to resolve proximal cap ambiguity and guide precise puncture; second, in cases of unsuccessful true lumen crossing, to identify extraplaque guidewire position and assist re-entry into the true lumen. We report a case of proximal left anterior descending artery CTO treated using combined HDR and tip detection-antegrade dissection and re-entry (TD-ADR). Initial HDR produced patchy Type 1 staining, generally indicating intraplaque tracking. Second and third subsequent contrast injections again demonstrated Type 1 staining; however, true lumen crossing with polymer-jacketed wires (Sion Black and Gladius EX) was unsuccessful. IVUS confirmed subintimal wire position. To avoid stiff wire escalation and maintain control, we switched to IVUS-guided TD-ADR. Spatial alignment enabled re-entry into the distal true lumen with a Conquest Pro 12 Sharpened Tip wire. A drug-eluting stent was implanted with excellent angiographic results and no complications. This case illustrates the complementary roles of HDR and TD-ADR in antegrade CTO PCI. HDR promotes early plaque modification and facilitates wiring with minimal perforation risk, but does not ensure intraplaque tracking. IVUS-guided TD-ADR offers a safe bailout when true lumen crossing fails. A stepwise, imaging-guided approach integrating both techniques may improve procedural success.