Tip detection–antegrade dissection and re-entry for bailout of iatrogenic dissection in an acute coronary syndrome patient: a case report

Guidewire-induced coronary artery dissection (CAD) during percutaneous coronary intervention (PCI) poses significant challenges, mainly when subintimal wiring causes extensive haematoma that compresses the true lumen. If rewiring from the entry point of the dissection with intravascular ultrasound (IVUS) guidance is unsuccessful, bailout options are limited.

Tip detection–antegrade dissection and re-entry (TD-ADR) was originally developed as a guidewire crossing technique for chronic total occlusion (CTO) PCI. It uses IVUS to penetrate from the extra-intima to the intima, confirming the tip of the stiff wire in real time. A high success rate has been reported.

A 79-year-old woman presented with ST-segment elevation myocardial infarction caused by severe stenosis in the left anterior descending artery (LAD) due to an eccentric calcified nodule. During PCI, guidewire manipulation resulted in a subintimal haematoma, leading to LAD occlusion and haemodynamic collapse. Initial bailout strategies, including parallel wire and IVUS-guided rewiring, were unsuccessful due to severe proximal calcification and stenosis. With coronary artery bypass grafting unavailable, TD-ADR was performed. Re-entry into the true lumen was achieved, followed by drug-eluting stent implantation, restoring good flow. The patient recovered well, was discharged on day 19, and remained symptom-free at 6 months follow-up.

This case demonstrates the potential of TD-ADR as a bailout strategy in acute coronary syndrome patients with complex CADs where conventional methods fail. TD-ADR enabled precise re-entry and successful revascularization, highlighting its applicability beyond CTO PCI. Familiarity with TD-ADR techniques in routine practice may facilitate their application in life-threatening emergencies.