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Case 15: Rotational Atherectomy and DES of CTO RCA BMS ISR

Case Presentation

  • A 55-year-old woman presented with angina chest pain and dyspnea on exertion.
  • A stress MPI revealed moderate antero-septal, and inferior ischemia with mild inferior infarct.
  • Medical History: Hypertension, Hyperlipidemia, ESRD on HD
  • Medications: ASA 81mg, Clopidogrel 75mg, Metoprolol XL 50mg, Isosorbide mononitrate 30mg, Atorvastatin 40mg, Ranitidine 300mg
  • Coronary angiogram revealed 2 V CAD; 95% prox RCA, 100% distal RCA BMS ISR and distal vessel fills via LAD collaterals, 90% mid LAD with LVEF 60% and Syntax score of 16.
  • Planned for IVUS/OCT guided rotational atherectomy and staged PCI of CTO RCA

Case Description

Pre Angiogram

PCI Strategy

  • ISR CTO length ~ 10-15mm with Collateral ++
  • Type: BMS ISR CTO
  • Antegrade approach with AWE (Fielder/FineCross > MiracleBros or Gaia > Confianza 12)
  • May require Rotational Atherectomy for lesion modification with extra support Rotawire


  • First, we used Fielder and FineCross microcatheter.
  • Then the wire was exchanged to MiracleBros 6 (Open Coil, Straight tip, high tip stiffness > facilitate for drilling) together with FineCross microcatheter.
  • Finally, MiracleBros 6 (Tip load of 8.8g) crossed the CTO.

Wiring Technique


  • Then, we exchanged MiracleBros with extra support Rotawire to perform rotational atherectomy (RA) with 1.5 burr.
  • Extra support Rotawire has longer spring tip (2.8 cm) compared to Rota floppy (2.2cm) with shorter wire transition at the tip.
  • After RA and atherotomy using flextome 3.25/6mm, three DES (3.5/32mm, 3.5/38 mm, 2.5/24mm) were placed in proximal, mid and distal RCA with an excellent result.

Wire Selection in Rotational Atherectomy

Final Angiogram

Learning Points

  • In BMS/DES ISR CTO intervention, the presence of stent will help in wiring step and may not require dual injection.
  • A stiffer wire with higher tip load is mostly required to go through ISR CTO segment and could use MiracleBros 6, Gaia 3, or Pilot 200T.
  • Rotawire selection is paramount and Rotawire Extra Support is particularly useful in ostial lesion, distal and angulated lesion.
  • One should have a low threshold to use an additional atherotomy as needed, even after rotational atherectomy performed.

Left Main DK Crush Video ID