Controlled antegrade intimal tracking with subintimal balloon inflation as a novel bailout technique for chronic total occlusion after failed intravascular ultrasound-guided parallel wire technique

Failure to cross with a guidewire is the most common reason for failure of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). In cases of CTO PCI with no interventional collaterals, an intravascular ultrasound (IVUS)-guided parallel wire technique is usually the last-resort procedure. Failure of this technique sometimes causes enlarged subintimal space, resulting in procedure failure. We present a successful second attempt at left anterior descending artery CTO PCI with no interventional collaterals. After IVUS-guided parallel wire technique failed with an enlarged subintimal space, successful antegrade wire crossing was achieved using controlled antegrade intimal tracking with balloon inflation in the subintimal space to deflect a second wire. This technique may be useful as a bailout strategy in otherwise-failed CTO PCI with an enlarged subintimal space.