Rotational Atherectomy is an advanced interventional technique used to modify heavily calcified coronary lesions that resist conventional balloon dilation and impede optimal stent delivery. As calcified atherosclerotic disease becomes increasingly common in aging populations, interventional cardiologists frequently seek updated knowledge on device selection, procedural safety and successful lesion preparation through expert cardiology conference platforms. Because the technique remains central to complex PCI, understanding its mechanics, indications and complications is essential for safe and effective coronary plaque modification.

The session begins by reviewing the burden and behaviour of calcified coronary disease. Participants explore how concentric, nodular or eccentric calcium affects compliance, disrupts lesion crossing and impairs stent expansion. Anatomical predictors, intravascular imaging markers and clinical risk factors are highlighted to support appropriate pre-procedural planning. Imaging modalities—including intravascular ultrasound and optical coherence tomography—are discussed for their ability to characterise calcium depth, distribution and arc, informing whether rotational atherectomy or alternative plaque-modifying techniques should be selected.

Technical principles form a major part of the discussion. Attendees examine burr sizing, guide-catheter choice, wire selection and rotational speeds that optimise lumen enlargement while minimising complications. The concept of “pecking motion,” gradual advancement and avoidance of prolonged runs are emphasised to prevent thermal injury, slow-flow phenomena and vessel perforation. Participants review strategies for managing difficult anatomies such as tortuous vessels, ostial lesions and bifurcations where rotational atherectomy may require staged or hybrid approaches.

Case-based examples illustrate how combining rotational atherectomy with other modalities—like intravascular lithotripsy, cutting balloons or high-pressure non-compliant balloons—can enhance lesion preparation. The session also explores peri-procedural pharmacology, including anticoagulation strategies, vasodilator administration and methods for mitigating no-reflow.

Complication management is addressed through practical algorithms covering burr entrapment, microvascular dysfunction, dissection and guide-catheter instability. Participants learn when to convert to alternative strategies, escalate imaging or adopt bailout techniques, fostering confidence during challenging interventions.

Post-procedural considerations include optimal stent selection, ensuring full expansion, avoiding malapposition and using intravascular imaging to confirm final results. The session emphasises long-term follow-up, dual-antiplatelet therapy and surveillance for restenosis or recurrent angina in high-risk patients.

Looking ahead, clinicians explore emerging technologies such as new-generation diamond-coated burrs, improved drive systems and integration with real-time imaging overlays. By the end of the session, participants will have a comprehensive, technically grounded understanding of rotational atherectomy, enabling them to enhance safety, precision and procedural success in complex PCI cases.