Synergistic Application of HydroDynamic contrast Recanalization and IVUS-Guided Tip Detection-Antegrade Dissection...

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.