OTW balloon-facilitated antegrade true lumen puncture (OFATP): a novel simplified technique for chronic total occlusion recanalization-a case report.

Background: Achieving precise guidewire puncture into the intraplaque entry point remains a key challenge in antegrade chronic total occlusion (CTO) intervention, as not all lesions have a side branch adjacent to the entry point for real-time intravascular ultrasound guidance. This difficulty is a major contributor to subsequent haematoma expansion, intervention failure, and even complications. Case summary: A 48-year-old man was admitted for heart failure with mildly reduced ejection fraction. Coronary angiography revealed two-vessel disease: two-segment severe stenosis of the right coronary artery (RCA) and a CTO of the proximal left anterior descending (LAD) artery. The patient declined coronary artery bypass grafting and consented to percutaneous coronary intervention. A staged approach was adopted, with RCA intervention performed first, followed by readmission for elective LAD intervention. During LAD intervention, over-the-wire balloon-assisted guidewire puncture enabled efficient antegrade guidewire crossing of the occluded segment into the distal true lumen. The patient was asymptomatic and was discharged 2 days postoperatively. Discussion: This case highlights the potential utility of OTW balloon-facilitated antegrade true lumen puncture (OFATP) as an interventional technique in the antegrade approach.