Navigating a Recanalized RCA CTO Case With Antegrade Dissection and Re-Entry

OBJECTIVES: To describe a reproducible, stepwise hybrid approach to a balloon- and microcatheter uncrossable recanalized right coronary artery with a distal chronic total occlusion (CTO) in a postcoronary artery bypass grafting patient with reduced ejection fraction. KEY STEPS: 1) Dual injections for distal target definition and collateral assessment; 2) Antegrade wiring escalation with recognition of a proximal uncrossable segment; 3) Retrograde right coronary artery collateral wiring attempts; 4) Rotational atherectomy for proximal plaque modification enabling CTO equipment delivery; 5) Stingray-based antegrade dissection and re-entry using a stick-and-swap technique; 6) Intravascular ultrasound confirmation of true-lumen position and landing zones; and 7) Stenting with TIMI flow grade 3 restoration. POTENTIAL PITFALLS: Failed rotational atherectomy wire delivery can be addressed by applying other lesion-modifying techniques, retrograde externalization, extraplaque plaque modification, or a more proximal subintimal entry for antegrade dissection and re-entry. Failed antegrade dissection and re-entry without a retrograde option may require converting to an investment procedure. TAKE-HOME MESSAGE: CTO percutaneous coronary intervention techniques can be performed in non-CTO uncrossable lesions; however, early failure-mode recognition and timely strategy escalation are critical for procedural safety and success.