Background: In primary percutaneous coronary intervention (PCI) for acute myocardial infarction, we occasionally experience challenging cases where conventional guidewires cannot pass through the lesion. In such cases, if the use of a tapered guidewire or polymer jacket guidewire is also unsuccessful, coronary artery bypass surgery becomes inevitable. Therefore, other methods to enable revascularization in a reliable and timely manner are desirable.
Case summary: We present the first case of intravenous ultrasound (IVUS)-guided tip detection (TD)-antegrade dissection re-entry (ADR) in a 73-year-old man who suffered ST-segment elevation myocardial infarction (STEMI). The patient had a total thrombotic occlusion of the right coronary artery and stenotic lesion of the left anterior descending artery. Primary PCI was unsuccessful and IVUS-guided rewiring using a chronic total occlusion (CTO) wire failed due to thrombus attenuation. However, IVUS imaging revealed the presence of intimal and subintimal space, which led us to perform IVUS-guided TD-ADR using Conquest Pro 12 ST (Asahi Intecc). Using the TD method, we were successful in swiftly puncturing the true lumen wall, and a stent was implanted following successful re-entry. Final angiography showed the establishment of Thrombolysis in Myocardial Infraction-3 flow and resolution of ST-segment elevation.
Discussion: IVUS-guided TD enables accurate puncture in an ADR procedure, enabling successful recanalization in a relatively short time. Thus, IVUS-guided TD-ADR is a reliable option for revascularization in STEMI cases wherein the guidewire fails to pass the occlusion using conventional techniques.
Keywords: Antegrade dissection rewiring; Case report; Coronary intervention; IVUS-guided tip detection; ST-segment elevation myocardial infraction.
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.