Wire bias modification with reverse orbital atherectomy for safer rotational atherectomy in calcified bifurcation.

Although debulking devices are very useful in modifying calcified plaques, their effectiveness is highly dependent on wire bias. In particular, in eccentric calcified bifurcation lesions, wire bias tends to be poor and needs to be corrected for adequate lesion preparation. A 67-year-old man was diagnosed with exertional angina pectoris. Coronary angiography showed a highly calcified eccentric lesion from the left main trunk to the left anterior descending artery. The patient refused coronary artery bypass surgery, therefore we decided to treat this complex bifurcation lesion with percutaneous coronary intervention. Initially, we performed reverse orbital atherectomy (OA) and sifted the guide wire position into the calcified plaque successfully. We continued with rotational atherectomy (RA) using a 2.0 mm burr and were able to obtain sufficient lumen without complications. Finally, the lesion was dilated with a cutting balloon and a drug-coated balloon to obtain a stent-like result. This case demonstrates that wire bias modification with reverse OA enables us to perform more aggressive and effective RA safely in eccentric calcified bifurcation lesions. This combination atherectomy can become an attractive approach in eccentric calcified bifurcation lesions. Learning objective: Atherectomy devices are helpful for lesion modification in calcified lesions but their effectiveness is highly dependent on wire bias. If the wire bias can be intentionally moved to an optimal position, it can be a very effective procedure in the treatment of calcified lesions. Wire bias modification by reverse ablation with orbital atherectomy that we have demonstrated enables subsequent aggressive rotational atherectomy and this combination atherectomy can be an attractive approach in eccentric calcified lesions.