Successful recanalization of a calcified, collateral-poor LAD-CTO via repeat antegrade dissection and re-entry guided by intravascular ultrasound after prior subintimal plaque modification: a case report

Chronic total occlusion (CTO) of the left anterior descending artery (LAD) with poor collateral circulation poses significant procedural challenges. Subintimal plaque modification (SPM) followed by repeat antegrade dissection and re-entry (ADR) under intravascular ultrasound (IVUS) guidance may enhance recanalization success. A 53-year-old male with prior non-ST-elevation myocardial infarction underwent failed initial percutaneous coronary intervention (PCI) for a stump-free, heavily calcified LAD-CTO with poor collaterals. After SPM, repeat angiography at 3 months revealed improved vessel architecture. IVUS-guided ADR was successfully performed, achieving full revascularization. At 4-year follow-up, the patient remained asymptomatic without major adverse cardiac events (MACE). In complex LAD-CTO lesions, SPM combined with IVUS-guided repeat ADR represents a viable bailout strategy, particularly when conventional antegrade/retrograde approaches fail.