ADR (Antegrade Dissection and Re-Entry) has historically been viewed as unpredictable — but with a structured, IVUS-sighted approach, it becomes one of the most consistent and controllable CTO PCI techniques.
In this detailed case walkthrough, Dr. Robert Riley demonstrates how he performs an IVUS-Sighted ADR workflow during a complex RCA CTO. He explains how to select landing zones, create a controlled knuckle, prevent hematoma formation, orient the Stingray system correctly, and re-enter the true lumen with precision.
Topics you’ll learn:
When ADR is the correct strategy for a long CTO
Identifying a clean distal landing zone using IVUS
How to form a stable knuckle with the Pilot 200
The purpose of de-escalating to Mongo for safer advancement
Hematoma prevention with guide extension support
How retrograde angiography guides Stingray orientation
Vacuum decompression (“straw technique”) for clearing the subintimal space
Stick-and-drive vs stick-and-swap re-entry patterns
Using IVUS to confirm true lumen passage and guide stent size
Avoiding the most common ADR failure modes
This is a foundational training for operators refining modern ADR technique with IVUS guidance.
Chapters:
00:00 – Why ADR still matters in modern CTO PCI
01:00 – When ADR is favored over wire escalation
02:00 – Identifying the distal landing zone with IVUS
03:30 – RCA CTO setup and planning
05:30 – Bifemoral access and guide selection
06:30 – Creating a knuckle with the Pilot 200
08:30 – De-escalating the knuckle and reducing subintimal trauma
10:30 – Guide extension support and pressure control
11:30 – Stingray preparation and system orientation
12:30 – Selecting the correct projection angle
14:00 – Retrograde angiography for confirmation
15:00 – Vacuum decompression (“straw technique”)
17:00 – Stick-and-swap method to regain the true lumen
19:00 – IVUS confirmation and how to size stents correctly
21:00 – Final angiographic review and procedural takeaways
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