66 Yr Old male with Diabetes, HTN , Dyslipidaemia presented with Angina Class III diagnosed as NSTEMI with Acute Decompensated Heart Failure with Moderate LV systolic dysfunction. on the basis of History and investigations patient taken up for coronary angiogram which revealed triple vessel disease

V1.mov

A temporary pacing lead was placed in view of triple vessel disease and potential for bradyarrhythmias during atherectomy.
A 6F JR guiding catheter was engaged at the RCA ostium. The lesion was initially crossed using a Sion Blue wire, which was parked distally into the posterior descending artery (PDA).A 0.75 mm CTO balloon was then advanced but failed to cross the heavily calcified lesion. The wire was subsequently exchanged for a RotaWire, and rotational atherectomy was performed in three sequential runs:

1. Proximal to mid RCA
2. Mid RCA
3. Mid to early distal RCA

using a 1.25 mm burr at 160,000 rpm.Following atherectomy, IVUS pullback demonstrated significant calcium modification and presence of calcium cracks. Lesion preparation was further done with 2.5 mm and 2.75 mm semi-compliant balloons. Subsequently, two overlapping drug-eluting stents (DES) were deployed and post-dilated with a 3.5 mm non-compliant balloon.Final IVUS pullback confirmed good minimal lumen area (MLA) gain, optimal stent apposition, and TIMI III flowwas achieved angiographically.

V1.mov
V2.mov

A temporary pacing lead was placed in view of triple vessel disease and potential for bradyarrhythmias during atherectomy.
A 6F JR guiding catheter was engaged at the RCA ostium. The lesion was initially crossed using a Sion Blue wire, which was parked distally into the posterior descending artery (PDA).A 0.75 mm CTO balloon was then advanced but failed to cross the heavily calcified lesion. The wire was subsequently exchanged for a RotaWire, and rotational atherectomy was performed in three sequential runs:

1. Proximal to mid RCA
2. Mid RCA
3. Mid to early distal RCA

using a 1.25 mm burr at 160,000 rpm.Following atherectomy, IVUS pullback demonstrated significant calcium modification and presence of calcium cracks. Lesion preparation was further done with 2.5 mm and 2.75 mm semi-compliant balloons. Subsequently, two overlapping drug-eluting stents (DES) were deployed and post-dilated with a 3.5 mm non-compliant balloon.Final IVUS pullback confirmed good minimal lumen area (MLA) gain, optimal stent apposition, and TIMI III flowwas achieved angiographically.



V1.mov
V2.mov

When even the smallest CTO balloon failed to cross, the burr became the breakthrough. Rotational atherectomy transformed an unyielding, calcified RCA into a successfully revascularized vessel. Guided by IVUS and supported by meticulous technique, the procedure achieved excellent stent expansion, optimal apposition, and restored TIMI III flow — reaffirming that in complex, calcified coronary lesions, Rota ablation remains the key when nothing else can pass