Rotational atherectomy has not vanished from left main practice, but its role has narrowed, and this facilitated module asks learners to say precisely where it now belongs. One unfolding, planning-stage case of circumferential ostial-to-distal left main calcium carries the group from imaging to aorto-ostial stent optimisation. The case is de-identified and no procedural outcome is described. Related modules sit in our interventional course library.
Learning objectives for the rotational atherectomy module
- Decide when rotational atherectomy is still required, when intravascular lithotripsy (IVL) should come first, and how the two are sequenced.
- Read a non-inferiority trial for its endpoint, its margin and the lesions it left out.
- Design a test inflation that predicts tolerance of repeated left main occlusion.
- Size devices in a large left main and choose a guide that carries them.
- Set IVUS expansion targets at the aorto-ostium and anticipate recoil.
Stage one: presentation and the heart-team conversation
What the learner sees
A seventy-five-year-old woman, ejection fraction sixty percent, whose mid right coronary artery has already been treated with PCI. Calcium runs from the left main ostium to its distal end, with an eighty percent mid LAD and a ninety percent proximal circumflex stenosis.
Facilitator question
“What does the treated right coronary change about this plan, and who else belongs in the discussion?”
Teaching answer
That right coronary is now her lifeline whenever the left main is occluded, so its result is checked first: no residual narrowing, dissection or sluggish flow. Left main disease with LAD and circumflex lesions merits a heart-team review. EXCEL and NOBLE found PCI comparable to CABG for isolated ostial or shaft disease of low complexity; the team records its reasoning without reopening that debate.
Stage two: IVUS and the device decision — rotational atherectomy, IVL, orbital or laser
What the learner sees
IVUS is used because OCT cannot reliably clear blood from a true ostium. It shows a full circumferential arc along the whole left main, reference about four point five millimetres. Assume thickness beyond half a millimetre and length beyond five millimetres: a Fujino score of four, where stent expansion fell to seventy-eight percent against ninety-six percent at lower scores.
Facilitator question
“Rank rotational atherectomy, IVL, orbital atherectomy, laser and a cutting balloon. What single finding would reorder your list?”
Teaching answer
Crossable, concentric calcium: IVL first. It carries the lowest perforation and slow-flow risk, cannot trap a burr, and cracks deep as well as superficial calcium. Rotational atherectomy leads when a one point five millimetre balloon will not cross or dilate, when the lumen is too tight for the IVL balloon to meet the wall, or when an eccentric nodule dominates.
Rotational atherectomy followed by IVL, often called RotaTripsy, uses a one point two five to one point five millimetre burr to open a channel for lithotripsy, not to debulk to vessel size.
Now the evidence exercise. ROLLER COASTR-EPIC22 randomised one hundred and seventy-one patients at eight Spanish centres. OCT stent expansion was eighty-six point four percent with rotational atherectomy against eighty-five point six percent with lithotripsy, so IVL was non-inferior; laser, at eighty point three percent, was not. Complications were numerically lowest with IVL. Vessels were two point five to four millimetres; no left main was studied.
ICARE OFDI randomised one hundred and sixty-nine patients. Minimal stent area was six point zero square millimetres with IVL and five point nine with rotational atherectomy, inside a zero point seven five square millimetre margin. Adequate expansion was sixty-five point one percent in both arms, but major malapposition was commoner after atherectomy, eighty point two against fifty-seven point eight percent.
Ask what the trials exclude. ICARE required lesions crossable with a two millimetre balloon, excluded the left main, and its authors call rotational atherectomy indispensable for uncrossable or resistant lesions. Non-inferiority holds only within one margin and one population. No randomised IVL-versus-atherectomy trial has enrolled a left main; that evidence is registries and case reports.
Orbital atherectomy is avoided at the aorto-ostium, where the crown cannot orbit safely and the guide is unstable; ECLIPSE found no advantage over balloon preparation. Laser is a bail-out tool.
Stage three: the NC test inflation and left main occlusion tolerance
What the learner sees
A fellow proposes a cutting balloon for the test inflation “so it also prepares the lesion”.
Facilitator question
“Which balloon, what pressure, how long, and what will you record? Why not a cutting balloon?”
Teaching answer
Take an undersized NC balloon, three point zero by eight to twelve millimetres, or two point five if tight. Inflate up to about twelve atmospheres for fifteen to twenty seconds, one IVL cycle, with the guide disengaged as it will be for lithotripsy. Record pressure nadir, ST onset, arrhythmia, symptoms and recovery time.
Pressure holding with recovery inside thirty to sixty seconds permits unsupported IVL; a waist at twelve atmospheres confirms the need for it. A steep fall, ventricular tachycardia or slow recovery means shorter cycles on vasopressors, rotational atherectomy first, or IVL under an Impella CP.
Atherectomy is non-occlusive but not ischaemia-free: slow flow across a diffusely calcified left main is global ischaemia. The cutting balloon inflates slowly, its blades blur the dilatability read-out, and it risks dissection into the aortic root. In PREPARE-CALC, two hundred patients, strategy success was eighty-one percent with modified balloons against ninety-eight percent with rotational atherectomy.
Each IVL cycle occludes the left main for fifteen to twenty seconds, like any NC inflation during left main stenting. Her normal ejection fraction and patent right coronary reassure. Poor-tolerance flags include hypotension, high filling pressure, significant valve disease, recent infarction and damping.
Keep mean pressure above eighty to eighty-five, pressors and pads ready, a circumflex buddy wire in place, and allow full recovery between cycles. Salazar, Escaned and colleagues treated two women in their nineties with five pulses per inflation and two wires, without mechanical support; both procedures succeeded.
Stage four: device sizing and rotational atherectomy delivery in a large left main
What the learner sees
A four point five millimetre left main; the largest coronary IVL catheter is four point zero by twelve millimetres.
Facilitator question
“Which size, how many positions and pulses, and if it will not cross, which burr?”
Teaching answer
Choose four point zero; the instructions advise the largest size when one-to-one is unavailable, and IVUS confirms contact at the narrowed calcified segments. Deliver at four atmospheres; pulsing higher to force apposition is off-label. Plan two positions, ostial and distal body, within eighty pulses per segment and one hundred and twenty per catheter. Branches get their own sized balloons.
If it will not cross, rotational atherectomy with a small burr opens the channel and IVL follows. Sandesara and colleagues compared IVL, with or without atherectomy, in fifty distal left main patients against rotational atherectomy alone in fifty-seven. Stent-area thresholds were met at similar rates and procedural success was ninety-eight against eighty-six percent. It was single-centre and non-randomised.
A diseased circumflex ostium makes this a true bifurcation needing a two-stent plan, with the left main prepared first.
Stage five: EBU three point five, seven French, and stent optimisation at the aorto-ostium
What the learner sees
A shelf of EBU, JL and AL guides in six and seven French, with and without side holes.
Facilitator question
“Choose one guide and defend its curve, size, French and tip.”
Teaching answer
EBU three point five, seven French, no side holes. It gives the backup a JL lacks, especially for the circumflex. Older women usually have smaller aortic roots, where a four point zero curve intubates deeply at a calcified ostium. Seven French takes two kissing balloons, two wires with IVUS, or a one point seven five millimetre rotational atherectomy burr. Side holes mask damping.
Engage to image, disengage to treat. After IVL, confirm fractures with a four point five NC under IVUS, implant a large-platform stent protruding one to two millimetres, post-dilate hard and flare the ostium.
A left main area of eight point two square millimetres, the commonly used IVUS threshold, is a floor; with a sixteen square millimetre reference, the author aims for twelve to thirteen. Oliveri and colleagues found aorto-ostial lesions reached under thirty percent residual stenosis less often, eighty-one point three against ninety point five percent, largely through recoil.
Facilitator notes and session plan
| Minutes | Segment | Activity |
|---|---|---|
| Zero to five | Objectives | Opening poll on atherectomy |
| Five to twelve | Stage one | Heart-team framing |
| Twelve to twenty-five | Stage two | Device ranking; groups dissect one trial each |
| Twenty-five to thirty-five | Stage three | Test inflation protocol |
| Thirty-five to forty-three | Stage four | Sizing arithmetic |
| Forty-three to fifty-two | Stage five | Guide shelf exercise |
| Fifty-two to sixty | Close | Misconceptions and repeat poll |
Common misconceptions to address
- “IVL has made rotational atherectomy obsolete.” The trials did not study the left main, and ICARE OFDI enrolled only crossable lesions.
- “Rotational atherectomy spares ischaemia.” Slow flow in a calcified left main is global ischaemia.
- “A cutting balloon makes a gentler test.” It is slower and riskier at the ostium.
- “Higher pulse pressure fills a big left main.” That is off-label.
- “Eight point two square millimetres is the target.” It is the minimum.
Companion reading: the cardiology books learning centre and the author’s learning centre.
References
- Jurado-Román A, et al. Rotational atherectomy, lithotripsy, or laser for calcified coronary stenosis: ROLLER COASTR-EPIC22. JACC Cardiovasc Interv. 2025. https://doi.org/10.1016/j.jcin.2024.11.012
- Honton B, et al. ICARE OFDI randomised trial. EuroIntervention. 2026. https://doi.org/10.4244/EIJ-D-26-00426
- Abdel-Wahab M, et al. PREPARE-CALC. Circ Cardiovasc Interv. 2018. https://doi.org/10.1161/CIRCINTERVENTIONS.118.007415
- Sandesara PB, et al. Calcified distal left main PCI. Catheter Cardiovasc Interv. 2023. https://doi.org/10.1002/ccd.30855
- Salazar C, et al. Lithotripsy for calcified left main stenoses. JACC Case Rep. 2019. https://doi.org/10.1016/j.jaccas.2019.05.008
- Fujino A, et al. OCT calcium score. EuroIntervention. 2018. https://doi.org/10.4244/EIJ-D-17-00962
- ECLIPSE investigators. Orbital atherectomy versus balloon angioplasty. Lancet. 2025. https://doi.org/10.1016/S0140-6736(25)00450-7
- Oliveri F, et al. IVL in aorto-ostial lesions. Catheter Cardiovasc Interv. 2024. https://doi.org/10.1002/ccd.31233