When the stent will not cross: True–false–true lumen wire tracking identified by intravascular ultrasound during complex LAD percutaneous coronary intervention

Failure of stent delivery despite successful guidewire and balloon passage represents a challenging scenario during percutaneous coronary intervention (PCI). Angiography alone may be insufficient to fully delineate intramural mechanisms underlying selective stent non-deliverability. A 73-year-old man presented with chest pain and elevated cardiac biomarkers. Coronary angiography revealed diffuse disease of the left anterior descending artery (LAD) and significant stenosis of the obtuse marginal (OM) branch. PCI to the OM branch was successfully performed. Although the guidewire and balloons crossed the LAD lesion without difficulty, repeated attempts to advance a drug-eluting stent were unsuccessful. Intravascular ultrasound (IVUS) revealed subintimal wire tracking with a true–false–true lumen configuration and an associated dissection flap, explaining the selective failure of stent delivery. Rewiring attempts during the index procedure were unsuccessful, and the intervention was deferred. At repeat intervention three days later, true-lumen access was successfully re-established using the parallel wire technique under IVUS guidance. A drug-eluting stent was deployed from the ostium to distal LAD, restoring TIMI III flow without residual dissection. This case illustrates how intramural wire tracking may cause selective stent non-deliverability despite preserved balloon crossability. IVUS provided mechanistic clarification and guided safe procedural strategy, underscoring the value of intravascular imaging in complex PCI. • Stent delivery failure can occur despite successful guidewire and balloon crossing. • IVUS identified true–false–true lumen wire tracking in a diffusely diseased LAD. • Angiography alone may not reveal intramural causes of stent non-negotiability. • IVUS-guided strategy enabled safe, staged completion of complex LAD PCI.