Background In primary percutaneous coronary intervention (PCI) for acute myocardial infarction, we occasionally experience challenging cases where conventional guidewires cannot pass through the lesion. In such cases, if the use of a tapered guidewire or polymer jacket guidewire is also unsuccessful, coronary artery bypass surgery becomes inevitable. Therefore, other methods to enable revascularisation in a reliable and timely manner are desirable. Case summary We present the first case of intravenous ultrasound (IVUS)-guided tip detection (TD)-antegrade dissection re-entry (ADR) in a 73-year-old man who suffered ST-segment elevation myocardial infarction (STEMI). The patient had a total thrombotic occlusion of the right coronary artery and stenotic lesion of the left anterior descending artery. Primary PCI was unsuccessful and IVUS-guided rewiring using a chronic total occlusion (CTO) wire failed due to thrombus attenuation. However, IVUS imaging revealed the presence of intimal and subintimal space, which led us to perform IVUS-guided TD-ADR using Conquest Pro (Asahi Intecc). Using the TD method, we were successful in swiftly puncturing the true lumen wall, and a stent was implanted following successful re-entry. Final angiography showed the establishment of Thrombolysis in Myocardial Infraction-3 flow and resolution of ST-segment elevation. Discussion IVUS-guided TD enables accurate puncture in an ADR procedure, enabling successful recanalisation in a relatively short time. Thus, IVUS-guided TD-ADR is a reliable option for revascularisation in STEMI cases wherein the guidewire fails to pass the occlusion using conventional techniques.