Guidewire Manipulation‐Directed IVUS‐Guided Antegrade Dissection and Re‐Entry Without Dedicated Devices

BACKGROUND: Intravascular ultrasound (IVUS)-guided antegrade dissection and re-entry (ADR) is an emerging strategy for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). However, its adoption has been limited by the perceived requirement for dedicated IVUS systems and specialized puncture guidewires. We describe a guidewire manipulation-directed IVUS-guided ADR technique using widely available equipment. CASE SUMMARY: A patient with a complex left anterior descending artery CTO underwent guidewire manipulation-directed IVUS-guided ADR using a conventional long-tip Insight LifeTech IVUS catheter and a handmade 45°-shaped 12-g polymer-jacketed guidewire. Following lesion preparation, true-lumen re-entry was achieved by manipulating the guidewire relative to a largely stationary IVUS catheter rather than repeatedly repositioning the IVUS transducer. The high-tip-load polymer-jacketed guidewire enabled controlled puncture and subsequent intraluminal advancement under IVUS guidance. The procedure resulted in successful microcatheter advancement, complete CTO recanalization, and implantation of three drug-eluting stents with an excellent final angiographic result. CONCLUSION: This report demonstrates the technical feasibility of guidewire manipulation-directed IVUS-guided ADR without dedicated devices. A conventional long-tip IVUS catheter and a polymer-jacketed high-tip-load guidewire may represent a practical alternative when dedicated equipment is unavailable, potentially expanding the applicability of IVUS-guided ADR. Further experience is required to establish the reproducibility and safety of this approach.