“Move the cap” technique for ambiguous or impenetrable proximal cap of coronary total occlusion

Antegrade crossing remains the most commonly employed crossing strategy for coronary chronic total occlusions (CTOs) but can be challenging to perform in cases of ambiguous or impenetrable proximal cap. To successfully treat such cases, we describe a technique named "move the cap," in which the subintimal space is entered proximal to the proximal cap using a stiff coronary guidewire or facilitated by inflating a slightly oversized balloon. Subintimal guidewire entry is followed by standard antegrade dissection and re-entry. The "move the cap" technique can facilitate crossing of CTOs with ambiguous or impenetrable cap, while minimizing the risk of perforation. This technique is also useful for treating balloon uncrossable lesions.