Objective: To describe the step-by-step optical coherence tomography-guided rotational atherectomy and intravascular lithotripsy for treating substantial coronary calcified nodules.

Key Steps: Initial rotational atherectomy with a 1.5-mm burr; Multiple optical coherence tomography imaging to assess lesion morphology; Upsizing the rotational burr to 2.0-mm for further de-bulking; Adjunctive intravascular lithotripsy with a 3.5-mm Shockwave balloon; Final stent deployment and optimization.

Potential Pitfalls: Potential complications: Burr entrapment during rotational atherectomy; Inadequate lesion modification with initial rotational atherectomy; Failure to achieve deep calcium fractures leading to stent underexpansion.

Tips to avoid: Start with a smaller burr size and use a slow pecking motion; Conduct meticulous intravascular imaging assessment; Upsize the burr and adjunctive intravascular lithotripsy based on intravascular imaging findings.

Take Home Messages: Detailed intravascular imaging is crucial for guiding personalized treatment strategies; Combining rotational atherectomy and intravascular lithotripsy (RotaTripsy) provides a synergistic approach for treating extensive calcified nodules.

JACC Case Reports Interim Editors-in-Chief 

Gilbert H. L. Tang, MD, MSc, MBA

CME Editor 

Kenneth A. Ellenbogen, MD

Author

Valerian L. Fernandes, MBBS, FACC

William Meeks, MD

Important Dates

Date of Release: October 2, 2024 

Term of Approval/Date of CME/MOC Expiration: October 1, 2025