In-stent Carlino-a novel bailout for device-uncrossable in-stent chronic total occlusions.

Background and aims: In-stent chronic total occlusion (IS-CTO) remains a challenging subset of coronary interventions, frequently demonstrating device uncrossability despite successful wire crossing. The in-stent Carlino technique can serve as a feasible and safe bailout strategy for device-uncrossable IS-CTOs. Methods: We present two cases of complex IS-CTOs in which successful wire crossing was achieved but device delivery failed despite exhausting appropriate support techniques. In-stent Carlino was performed using controlled contrast injection (0.5 mL) through a wedged microcatheter to create hydraulic plaque modification. Results: Both cases achieved successful device delivery following in-stent Carlino application. The technique facilitated microcatheter advancement and subsequent lesion treatment without complications. The metallic stent framework and dense neoatherosclerotic tissue provided natural containment, preventing extension of the dissection to extra-plaque. Conclusions: In-stent Carlino offers an effective bailout for device-uncrossable IS-CTOs. Compared with conventional Carlino applications, safety is enhanced by the natural containment provided by the stent architecture.