The Slipstream and Tip-Detection Technique: A Simplified AnteOwl-IVUS-Guided Re-Entry Strategy for Complex Lower-Extremity CTOs

Long lower-extremity chronic total occlusions (CTOs) often require subintimal passage, and controlled true-lumen crossing can be challenging, particularly when (1) the distal true lumen is reached, but part of the CTO is subintimal or (2) the first wire stalls subintimally without distal access. We report 2 patients with common iliac or superficial femoral artery CTOs treated with AnteOwl WR intravascular ultrasound (AO-IVUS)-guided slipstream and tip-detection. AO-IVUS was advanced over the first wire using the first-wire lumen only, and a dual-lumen microcatheter was tracked along the same wire (slipstream). Under IVUS tip-detection, a second guidewire was redirected into an all–true-lumen or functionally intraluminal course, enabling definitive stent or drug-coated balloon therapy without distal puncture or dedicated re-entry devices. AO-IVUS-guided slipstream and tip-detection may be a practical bailout strategy for complex aortoiliac and femoropopliteal CTOs.