This is a 71 years old man presented to us with stable coronary artery disease with refractory angina. His past medical history was significant for hypertension, hyperlipidemia, chronic kidney disease, previous atrioventricular block with pacemaker implanted. He presented to us for refractory angina despite multiple anti-anginal drugs. Physical examination was unremarkable.

Echocardiography showed preserved systolic function with normal valves. 

Cardiac catheterization showed Left main mild dis, mid-LAD CTO. Proximal LCX ulcerative plaque with 90% stenosis. RCA mild dis. Faint right to left collaterals seen. PCI to LCx was done and plan stage PCI to LAD CTO. During PCI to LAD CTO, we encounter significant difficult to wire into distal true lumen. After repeated attempt, we went in subintimal space with very distal reentry. To preserve septal branches, we decided to proceed with IVUS guided 3D wiring. 

Attempted PCI to LAD CTO. Turnpike 135 microcatheter, XTA guidewire with turnpike 135 microcatheter was unable to cross CTO Sion blue to first diagonal, Terumo anteowl IVUS done to identify CTO capXTA to first septal and IVUS done to identify CTO capGaia next 2nd crossed CTO and enter LAD subtintimal space, unable to re-enter Parallel wire with Gaia next 3 on Sasuke MC. Gaia next 3 successfully enter dLAD true lumenLAD predilated with 1.5 balloonIVUS done showing distal wire in true lumen. Long segment of subintimal wire Attempted IVUS guided wire re-entry, Anteowl IVUS identify site of re-entryHightrack 1.7 as microcatheter, conquest pro 12 successfully re-enter intraplaque on IVUS guidanceMC enter intraplaque and wire switched to sion black and enter dLAD true lumenFurther predilated and stented with good final result Good preservation of all septal branches 
MOVIE-0029.mp4
MOVIE-0059.mp4

CTO PCI can be challenging in many cases. There are more tools in our toolbox that can help to improve procedural success and reduce complication. This case demonstrated IVUS guided wiring with tip detection method is a reliable and useful way to improve CTO wiring success and reduce fluoroscopy time. It is also an essential tool to increase chance of intraplaque wiring position.