Keys to Successful Tip Detection–Antegrade Dissection and Re-Entry (TD-ADR)

The tip detection method using the AnteOwl WR intravascular ultrasound has improved the success rate of antegrade chronic total occlusion percutaneous coronary intervention (CTO-PCI). The tip detection-antegrade dissection and re-entry (TD-ADR) technique has demonstrated high procedural success and is increasingly adopted in CTO-PCI. Established technical principles include adequate visualization of the wire tip, minimal second-curve formation, and appropriate microcatheter selection and positioning. However, the selection of the puncture plane using intravascular ultrasound cross-sectional images along the extra-plaque guidewire course, as well as the puncture technique within that plane, often relies on operator intuition. We present 3 cases in which TD-ADR was initially challenging. In all cases, successful re-entry was achieved by selecting the puncture plane based on favorable second-wire bias toward the true lumen and by applying a structured 6-point puncture strategy within that plane. This structured approach may enhance the reproducibility and success of TD-ADR.