Aortic arch-assisted “Tip-in” technique in coronary intervention for ostial chronic total occlusion

Percutaneous coronary intervention (PCI) for ostial chronic total occlusion (CTO) remains technically demanding, and often requires the retrograde approach. We report a case of a 70-year-old man with a history of coronary artery bypass grafting who presented with exertional chest pain. Coronary angiography revealed a CTO at the ostium of the right coronary artery (RCA). Since an antegrade approach was unsuccessful, we performed a retrograde approach via septal collaterals, and then the guidewire successfully crossed the lesion into the aorta. Because we could not prepare an appropriate snare device, however, we employed an aortic arch-assisted “Tip-in” technique, in which the natural curvature and anatomical bias of the aortic arch were utilized to align and advance the retrograde guidewire into the antegrade guiding catheter under orthogonal angiographic guidance. This allowed for successful guidewire externalization and stenting for the RCA lesion. This technique provides a safe, efficient, and cost-effective in selected ostial CTO cases where standard coaxial alignment is difficult and adjunctive devices are not available.