Tip-in balloon grenadoplasty for uncrossable chronic total occlusions

In retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI), when the retrograde microcatheter (MC) fails to traverse the occlusion, precluding conventional guidewire externalisation, tip-in techniques have emerged as effective bailout strategies1. In cases where even this approach fails – specifically when the anterograde MC can cannulate the retrograde guidewire but cannot advance through the occlusion – external cap crush or switching to a last-resort rotablation wire may be considered, despite the risk of losing the established guidewire connection. This approach relies on the likelihood that the rotablation guidewire will successfully navigate through the created microchannel, a difficult task in long occlusions.

We present the case of a 60-year-old male patient undergoing right coronary artery CTO PCI, where retrograde wire escalation and tip-in techniques were performed. However, both MCs became lodged at a significant distance from each other (Figure 1A, Supplementary Figure 1) (antegrade MC: Corsair Pro 135 mm [Asahi Intecc]; retrograde MC: Turnpike LP 150 mm, [Teleflex]); additionally, due to length constraints (having only 100 cm catheters), the retrograde MC end reached the Y-connector – precluding...