Management of Chronic Total Occlusion With Heavily Calcified Distal Cap: Three‐Dimensional Vascular Wall Assessment Enables Move‐the‐Cap Technique via Retrograde Approach

The complexity of chronic total occlusion percutaneous coronary intervention (CTO PCI) involving calcification is high, and completing the procedure with an antegrade approach is often challenging. However, calcification is also a significant obstacle in the retrograde approach, where it has been reported as a predictor of CTO PCI failure even after successful channel crossing. Overcoming calcification in the retrograde approach is, therefore, crucial. CTOs with heavily calcified distal caps often hinder the advancement of retrograde wires, leading to procedure failure. This report discusses two cases where we successfully employed the retrograde move-the-cap technique to perform reverse-controlled antegrade and retrograde tracking and dissection in the presence of heavily calcified distal caps, enabled by precise three-dimensional assessment of the vascular wall from multiple angles based on appropriate landmarks.