When complications become opportunities: Guide catheter-induced dissection facilitating an unplanned investment strategy in chronic total occlusion PCI of the RCA

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of the right coronary artery (RCA) remains technically challenging. Guide catheter-induced dissection is typically considered a serious complication. However, in rare cases, such events may paradoxically aid in successful revascularization. We report the case of a 43-year-old male with prior coronary artery bypass grafting (CABG) and RCA CTO, who underwent unplanned investment PCI procedure. Immediately after guide catheter engagement, contrast injection revealed a proximal RCA dissection. Instead of terminating the procedure, this unintentional dissection enabled entry into the subintimal space and facilitated guidewire passage to the distal branches. Intravascular ultrasound (IVUS) confirmed entry into the false lumen. Serial balloon angioplasty was performed, restoring TIMI-III flow to the right posterior descending artery (RPDA) and right posterolateral artery (RPLA). Remarkably, the dissection did not extend to the aortic cusp, nor did it result in perforation or pericardial effusion. The case was deemed a successful investment procedure, with staged completion in 10 weeks when patient returned for definitive revascularization. Four overlapping stents were placed from ostial RCA to RPLA with excellent results. While coronary dissection during CTO-PCI is conventionally viewed as a complication, in select scenarios it may facilitate revascularization. Recognizing and managing such outcomes requires careful intraprocedural assessment and expertise in complex PCI. • A guide catheter-induced RCA dissection inadvertently enabled wire entry in a challenging CTO-PCI case. • Intravascular ultrasound (IVUS) was essential for confirming wire position within the false lumen and guiding procedural strategy. • Balloon angioplasty during the initial unplanned investment procedure restored TIMI-III flow, setting the stage for successful revascularization. • A staged IVUS-guided PCI with four overlapping drug-eluting stents was safely performed 10 weeks later, achieving complete RCA revascularization. • This case highlights the nuanced decision-making and adaptability required during CTO interventions.