Intravascular ultrasound-guided tip detection-antegrade dissection re-entry as a bailout technique for coronary artery dissection: a case report

Coronary artery dissection during percutaneous coronary intervention (PCI) may lead to haemodynamic collapse. Intravascular ultrasound (IVUS)-guided tip detection-antegrade dissection re-entry (TD-ADR) may serve as a bailout strategy. We describe a unique case in which IVUS-guided TD-ADR successfully achieved true lumen re-entry after severe coronary artery dissection.

A 64-year-old woman who had received long-term immunosuppressive therapy for rheumatoid arthritis was admitted for unstable angina. Subsequent evaluation revealed severe multivessel disease, and the patient underwent PCI of the left anterior descending artery (LAD). During the procedure, the patient experienced cardiac arrest, likely due to worsening global myocardial ischaemia, and required venoarterial extracorporeal membrane oxygenation support. IVUS demonstrated subintimal wire tracking with true lumen collapse. IVUS-guided TD-ADR using a high-penetration chronic total occlusion wire supported by a microcatheter enabled precise re-entry into the true lumen and successful LAD revascularization. Severe left circumflex artery stenoses were also considered to perpetuate myocardial ischaemia and haemodynamic instability, necessitating rescue PCI for haemodynamic stabilization. In addition, major bleeding complications due to guidewire-induced perforation of the right subclavian artery branch were managed using stenting and coil embolization. The patient showed recovery of left ventricular function and was discharged in stable condition. During the 8-month follow-up after discharge, the patient was free of adverse events.

This case highlights the feasibility of IVUS-guided TD-ADR as a bailout technique for coronary artery dissection during complex PCI. By enabling accurate true lumen re-entry, this approach facilitates timely revascularization and contributes to haemodynamic stabilization and recovery in a life-threatening setting.