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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