"Power knuckle" for facilitating the "move the cap" technique

Chronic total occlusions with proximal cap ambiguity remains the most challenging to recanalize and are associated with higher failure rate. We describe the "power knuckle" technique, in which the subintimal space proximal to the proximal cap is safely entered with a knuckle wire supported by a microcatheter and an inflated balloon. The "power knuckle" can facilitate entry into the extraplaque space for subsequent antegrade dissection and re-entry.