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Background  There is no consensus on the optimal guidewire passage route for femoropopliteal (FP) chronic total occlusion (CTO). If intraplaque wiring can be performed, a stent-less strategy using a drug-coated balloon can be realized even with FP CTO, and there is a high possibility that good expansion can be obtained even when stent deployment is performed. AnteOwl WR (AnteOwl) is a novel intravascular ultrasound (IVUS) device useful for navigating the second guidewire into the intraplaque route under IVUS observation from the subintimal space. Here, we describe representative cases of FP CTO in which CTO-specific IVUS was extremely useful.    Case presentation  Case 1 involved a 79-year-old man with total occlusion of the left superficial femoral artery (SFA). We used a contralateral antegrade approach, but the guidewire was advanced into the subintimal space. We advanced AnteOwl into the CTO. By utilizing the asymmetric structure of the transducer and the IVUS wire, we were able to reflect the positional relationship among the IVUS transducer, IVUS wire, and target plaque onto the angiographic image. By aiming the wiring in that direction, we succeeded in traversing the center of the plaque and finally succeeded in obtaining good expansion using the drug-coated balloon. Case 2 involved a 76-year-old woman with total occlusion from the SFA to the popliteal artery. We used an ipsilateral antegrade approach. When AnteOwl was placed on the wire and advanced to the popliteal artery, the subintimal space in the middle of the SFA could be visualized. We employed an IVUS-guided parallel wiring technique and succeeded in passing through all intraplaque routes. Although the CTO was long, we could easily advance through the intraplaque route by reflecting the information obtained from AnteOwl in angiography.    Conclusions  AnteOwl is an effective IVUS for FP CTO and facilitates a complex IVUS-guided procedure.

Efficacy of navigating through the intraplaque route using AnteOwl WR intravascular ultrasound in femoropopliteal chronic total occlusion