Minimalistic chronic total occlusion treatments using tip detection-antegrade dissection and re-entry: a case series

Background: Since chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is mainly aimed at symptom relief, it should avoid placing patients at risk. Tip detection-antegrade dissection and re-entry (TD-ADR), whose wiring time has been reported to be shorter compared to retrograde approach, do not need a dual access. Although the retrograde approach is effective, it is a significant risk factor for in-hospital adverse events after CTO PCI. We are advocating 'Minimalistic Approach with Tip detection-antegrade dissection and re-entry' (MAT) which positions antegrade wiring as the first, tip-detection intravascular ultrasound-guided wiring as the second, and the retrograde approach as the third option. Case summary: This case series describes three PCIs performed via a single radial access for right coronary artery CTOs characterized by a puncturable proximal cap and non-diffuse calcification. It was possible for TD-ADR to stick to the CTO body and preserves side branches distal to the CTO. Discussion: MAT enables antegrade CTO treatment with a single radial access. While TD-ADR is difficult in diffusely calcified CTO, complications of TD-ADR are limited to those that can be adequately anticipated and managed, unlike those associated with the retrograde approach. MAT likely reduces procedural risks and improves patient comfort.