The patient was a male in his 50s, he had several coronary risk factors that were hypertension, dyslipidemia, type2 diabetes and current smoker.He had been performed percutaneous coronary interventions several times before and had been implanted the DES for 3 vessels.He had continued to visit our institute, but he complained worsening chest pain recently.Because of his typical chest pain, we diagnosed him unstable angina and decided to perform coronary angiography.

Laboratory data revealed that mild kidney dysfunction and a little bit high of serum BNP, and there was no anemia.Electrocardiogram showed no ST change or arrhythmia.Chest X-ray revealed no symptom of heart failure.Echocardiography revealed reduced ejection fraction that was about 42%, and there was no obvious valvular disease.

Coronary angiography revealed that there was no stenosis in LAD, but there was severe stenosis in LCx seg11 to seg13 and occlusion at RCA seg3.LCx was diffuse lesion from ostium to seg13, and RCA was in-stent occlusion from seg3 to seg4PD and de novo lesion in seg1.In that time, we decided to recanalize for RCA lesion at first, and we finally succeeded recanalization for RCA lesion with scoring balloon and drug-coated balloon.And then, we planned to perform PCI for LCx lesion in next session.

We started the procedure by radial approach with 7Fr catheter.We chose the 7Fr guiding catheter (Hyperion SPB 3.75) and cross the sion blue wire to the distal site of LCx. IVUS revealed severe calcified plaque especially at ostial LCx.Therefore, we wanted to try rotablator to modify the calcified plaque and avoid cross-over stenting from LMT to LCx. However, wire bias was not reasonable because wire was not contacted to calcified plaque. In this situation, if we try to perform rotablator, we could not debulk the calcified plaque effectively.Calcified plaque of ostial LCx was opposite side of carina, and wire was center of the vessel and not touch the calcified plaque. Therefore, we thought rotablator was not effective but pull sanding of orbitalatherectomy might be effective and could change the wire bias or wire route in the lesion.For that reason, we tried the orbital atherectomy with only pull sanding (retrograde debulking). After orbital atherectomy, IVUS revealed effective debulking of calcified plaque, and wire route was changedinto the calcified plaque. Therefore, we changed the strategy from orbital atherectomy to rotablator with big burr because we could optimize of wire bias at ostial LCx.We debulked the ostial LCx by rotablator with 2mm burr and finally could enough debulking for the ostial LCx.Owing to enough debulking of ostial LCx, we could finalize the procedure by using drug-coated balloon in ostial LCx lesion and avoid cross-over stenting.

As is well known, orbital atherectomy (OA) and rotablator (RA) are completely different debulking device. Compared to RA, retrograde debulking (sanding) of OA is effective method or strategy.Retrograde debulking of OA could change the wire bias or route especially in severe tortuously lesions. If we can change the wire bias effectively, it might be possible to perform aggressive debulking safely by using big size burr of RA. However, debulking efficacy of OA is generally inferior to RA, and also OA is not suitable for a long lesion. Therefore, like in this case, sometimes combined use of OA and RAmight be extremely effective strategy.