Kidney disease, diabetes, and diameter stenosis predict Rotablation bailout in modified balloon application for severely calcified coronary lesions.

BACKGROUND: Modified balloon (MB) treatment in severely calcified coronary artery lesions is an established technique. However, some lesions require Rotablation (RA) as bailout strategy. AIMS: This study aimed to assess predictors of switch from MB to RA and its impact on procedural and midterm outcomes. METHODS: Four hundred and eighty-three consecutive patients were included undergoing MB treatment (n = 204) with a scoring or cutting balloon, or upfront RA treatment (n = 279) serving as control cohort. Strategy switch from MB to RA was performed in 19 of 204 patients. Procedural success was defined as successful stent implantation and TIMI III flow. RESULTS: In the MB cohort, median age was 72 [63-78] years, 75.5% were male and 42.1% had acute coronary syndrome. Procedure success was achieved in 89.4% of the switch group versus 98.4% of the MB only group (p < 0.001) and in 96.4% of the RA cohort. In the switch group, periprocedural complications (31.6% vs. 8.1% vs. 11.8%, p = 0.007), radiation dose (149 [126-252] vs. 59 [30-97] vs. 102 [59-156] Gcm2; p < 0.001) and contrast volume (250 [190-250] vs. 190 [150-250] vs. 195 [190--250] mL; p < 0.001) were significantly higher. Diabetes (OR 3.8, 95% CI 1.1-13.9, p = 0.042), chronic kidney disease stage 4 or 5 (OR 19.0, 95% CI 3.3-108.6, p < 0.001) and pronounced calcification resulting in higher angiographic diameter stenosis (OR 1.13, 95% CI 1.1-1.2, p = 0.001) independently predicted strategy switch. Midterm results were not affected by strategy switch regarding 1-year target lesion revascularization rates (86% vs. 89% vs. 89%; log-rank p = 0.95). CONCLUSION: Primary RA strategy might be considered in patients with severely calcified coronary artery lesions with high angiographic diameter stenosis, diabetes or impaired renal function due to increased periprocedural complication rates, radiation dose, and contrast volume following strategy switch.

Technical aspects of entrapped coronary guidewire retrieval using rotational atherectomy device: A case series.

BACKGROUND: This article highlights four unique cases where rotational atherectomy (RA Rotapro, Boston Scientific) was used to cut and retrieve an entrapped coronary guidewire with parts extending into the aorta We discuss the technique and step by step approach to the retrieval procedure. CASE SUMMARY: Three of four cases described a guide wire entrapment in the right coronary artery (RCA), and one in the left anterior descending artery via retrograde route. In all cases the guide wire was intact within the intracoronary segment. In Case 1, the guide wire (Runthrough; Terumo) was entrapped in an acute marginal branch during chronic total occlusion (CTO) percutaneous coronary intervention. In Case 2, a whisper wire (Abbott) was entrapped during re-wiring of the right posterolateral branch through stent struts, the traction on the wire caused severe malformation of distal and proximal stents requiring second staged procedure to complete revascularization of the RCA CTO. In Case 3, a Runthrough wire was entrapped between two layers of stents and fractured at the proximal point with filaments extending into descending aorta. And in Case 4, a Pilot 200 (Abbott) wire was entrapped retrograde in the subintimal space via saphenous vein graft connection by tying a knot at the distal tip of the wire. In all four cases RA was used to successfully cut and remove the entrapped guide wires. DISCUSSION: Rotablation technique appears to be a safe and effective strategy for the management of entrapped coronary guidewire when conventional strategies fail.

Intravascular lithotripsy to treat an underexpanded coronary stent: 4-Month angiographic and OCT follow-up.

We report the case of a 79-year-old man with stable angina who underwent percutaneous coronary intervention to a severe and calcified left circumflex lesion. Despite extensive preparation of the lesion with high-pressure balloon predilatation and rotablation, the implanted stent was grossly underexpanded and failed to respond to high-pressure balloon postdilatation. The patient was readmitted 6 weeks later for intravascular lithotripsy that resulted in excellent stent expansion. Coronary angiography with optical coherence tomography 4 months later revealed sustained acute lumen gain with no evidence of stent recoil or in-stent restenosis.

Feasibility and clinical outcome of rotational atherectomy in patients presenting with an acute coronary syndrome.

OBJECTIVES: We aimed to investigate the feasibility, safety, and outcome of rotational atherectomy (RA) in the setting of acute coronary syndrome (ACS). BACKGROUND: Limited data are available on the use of RA in patients presenting with ACS. METHODS: This analysis is from an observational registry, which enrolled all consecutive patients undergoing RA in a tertiary center. Between 2002 and 2015, 433 patients with stable coronary artery disease (SCAD) were treated with RA. Within the same period, 108 patients with ACS (8 STEMI and 100 NSTE-ACS) were treated with RA. Procedural success was similar between the ACS and the SCAD groups (96.6% vs. 96.4%, P = 0.90), and no significant difference was observed in procedural complications (slow-flow: 0.8% vs. 2.8%, P = 0.32; coronary dissection: 6.8% vs. 7.2%, P = 1.00; coronary perforation: 0.8% vs. 1.7%, P = 0.69). In-hospital MACE rates were comparable (3.7% vs. 3.2%, P = 0.77). The risk of MACE within 24 months was higher in ACS patients (39.9% vs. 22.4%, log-rank P = 0.002; HR: 1.39; 95% CI: 1.12-1.73; P = 0.003). Multivariable Cox regression analysis identified left ventricular ejection fraction (HR 0.97; 95% CI: 0.85-0.99; P = 0.001), treatment with a BMS (HR 2.22, 95% CI: 1.15-4.25, P = 0.02) or early generation drug eluting stent (HR 1.99; 95% CI 1.09-3.64; P = 0.03), as well as ACS presentation (HR 1.53; 95% CI: 1.02-2.29; P = 0.04) as predictors of MACE at two years. CONCLUSIONS: RA is technically feasible and safe in high risk patients presenting with ACS. However, successful application of RA did not mitigate the higher rate of long term cardiovascular events.

Treatment of rotablation-induced ostial left circumflex perforation by papyrus covered stent and its fenestration to recover the left anterior descending artery during CHIP procedure.

Coronary artery perforation is a rare complication of percutaneous coronary intervention (PCI). Covered stents have been successfully used in these situations. We report a case of ostial left circumflex (LCx) artery perforation during rotablation PCI of left main coronary artery (LMCA) and LCx artery. After failed attempts to balloon tamponade the perforation, a PK Papyrus covered stent was deployed from proximal LCx into LMCA. This resulted in acute exclusion of the left anterior descending (LAD) artery from coronary circulation. Using a dual lumen catheter, a stiff wire was advanced through the side port toward the occluded LAD to fenestrate the membrane of the covered stent. A series of balloons were used to dilate the fenestration in the covered stent to restore a normal flow into the LAD.

Transient rise in His-lead threshold due to acute myocardial infarction.

An 85-year-old male was admitted to our center with a non-ST elevation myocardial infarction. The patient had a dual-chamber pacemaker in situ with an atrial and His lead. A transient increase in His threshold and loss of nonselective capture occurred at the presentation of right coronary artery infarction, peaking during rotational atherectomy therapy causing loss of capture and complete atrioventricular block. A follow-up interrogation, 2 weeks postrevascularization, showed a return to a normal nonselective capture morphology and threshold measurements. Physicians should be aware of this complication in patients with His leads, particularly those with a history of coronary artery disease.

Predictors of in-hospital effectiveness and complications of rotational atherectomy (from the ORPKI Polish National Registry 2014-2016).

OBJECTIVE: The aim of the study was to assess trends in the use and periprocedural outcomes of rotational atherectomy (RA) in Poland between January 2014 and December 2016. BACKGROUND: In recent years, due to the aging population, RA is becoming more commonly used to treat heavily calcified coronary artery stenoses. METHODS: Data were prospectively collected using the Polish Cardiovascular Intervention Society national registry on all percutaneous coronary intervention (PCI) procedures performed in Poland. In total, 1,175 RA procedures were recorded from 317,175 PCI procedures (incidence of 0.37%). RESULTS: Patients undergoing RA were older (71.7 ± 9.7 vs. 66.9 ± 10.8, P < 0.00001) and less often males (68.3% vs. 76.4%, P < 0.00001). The complication rate was significantly higher in the RA group (P = 0.0012) with the leading coronary artery perforation (CAP) (P < 0.0001). Complication frequency decreased significantly in the last 3 years and was accompanied by an increase in the percentage of radial access and patients with stable angina. Among several predictors of the use of RA during PCI in multivariate analysis, the strongest one was previous coronary artery by-pass grafting (P < 0.0001), whereas the strongest, predictor of CAP was the RA procedure (P = 0.00004). The increase in RA frequency over the last 3 years may reflect population aging, some fluctuations in indications for RA and reimbursement policies. CONCLUSIONS: We observed a substantial increase in the utilization of RA during PCIs performed in Poland; however, it still needs to be increased. Decreased frequency of RA procedures follows change in indications for RA and vascular access. Periprocedural complication rates significantly decreased over the last 3 years.

Can bioabsorbable scaffolds be used in calcified lesions?

The technology of bioabsorbable vascular scaffolds (BVSs) that disappears with minimal trace essentially eliminating the risk of very late stent thrombosis appears exciting. However, these scaffolds have only been tried in simple lesions in which the risk of late stent thrombosis is very low. We would like to report the use of everolimus-eluting BVS in calcified coronary lesions following debulking the lesions using scoring balloons and rotational atherectomy. With the use of intravascular ultrasound, we have confirmed the adequate expansion of these scaffolds. These cases demonstrate the feasibility of BVS in complex lesions, but appropriate lesion preparation remains the key to aid adequate expansion of these scaffolds.

Successful calcium modification of a large calcified nodule using shockwave intravascular lithotripsy in the setting of acute coronary syndrome: a case report.

Background: Calcified nodules are associated with suboptimal preparation before stenting due to challenging crossing and unsuccessful pre-dilation and calcium cracking with conventional balloons. In this scenario, we report the use of shockwave intravascular lithotripsy for the successful lesion preparation of an undilatable and challenging calcified nodule in a patient presenting with ACS. Case summary: We report a case of a 79-year-old male patient presented with non-ST elevation myocardial infarction. Coronary angiography revealed 90% stenosis in the proximal segment of the right coronary artery, with a hazy area of inhomogeneous contrast. Intravascular ultrasound (IVUS) imaging identified a large eccentric calcified nodule, with a minimum luminal area (MLA) of 4.18 mm2. Rotablation was done with a ROTAPRO Atherectomy System, post-rotablation IVUS showed no plaque modification. Intravascular lithotripsy (IVL) was performed with the emission of 50 pulses. Post-IVL, IVUS showed that the calcium nodule was successfully cracked with increased MLA to 6.8 mm2. The lesion was pre-dilated with a cutting balloon and stented using a SYNERGY MEGATRON stent and post-dilated with a non-compliant balloon with good final angiographic result and TIMI Grade 3 flow. Post-stenting IVUS confirmed optimal stent apposition and expansion with an MLA of 11.9 mm2. Discussion: In severely calcified lesions, like calcified nodules, lesion preparation before stenting is pivotal for optimal long-term outcomes. As demonstrated in this case, IVL can be used safely in the setting of ACS not only to treat superficial and deep calcium layers but also to crack a large, calcified nodule, after failure of rotablation.

ShOckwave ballooN or Atherectomy with Rotablation in calcified coronary artery lesions: Design and rationale of the SONAR trial.

BACKGROUND: The percutaneous treatment of calcified coronary lesions remains challenging and is associated with worse clinical outcomes. In addition, coronary artery calcification is associated with more frequent peri-procedural myocardial infarction. STUDY DESIGN AND OBJECTIVES: The ShOckwave ballooN or Atherectomy with Rotablation in calcified coronary artery lesions (SONAR) study is an investigator-initiated, prospective, randomized, international, multicenter, open label trial (NCT05208749) comparing a lesion preparation strategy with either shockwave intravascular lithotripsy (IVL) or rotational atherectomy (RA) before drug-eluting stent implantation in 170 patients with moderate to severe calcified coronary lesions. The primary endpoint is difference in the rate of peri-procedural myocardial infarction. Key secondary endpoints include rate of peri-procedural microvascular dysfunction, peri-procedural myocardial injury, descriptive study of IMR measurements in calcified lesions, technical and procedural success, interaction between OCT calcium score and primary endpoint, 30-day and 1-year major adverse clinical events. CONCLUSIONS: The SONAR trial is the first randomized controlled trial comparing the incidence of peri-procedural myocardial infarction between 2 contemporary calcium modification strategies (Shockwave IVL and RA) in patients with calcified coronary artery lesions. Furthermore, for the first time, the incidence of peri-procedural microvascular dysfunction after Shockwave IVL and RA will be evaluated and compared.

Impact of the use of plaque modification techniques on coronary microcirculation using an angiography-derived index of microcirculatory resistance.

Many lesions in patients undergoing percutaneous coronary intervention (PCI) exhibit significant calcification. Several techniques have been developed to improve outcomes in this setting. However, their impact on coronary microcirculation remains unknown. The aim of this study is to evaluate the influence of plaque modification techniques on coronary microcirculation across patients with severely calcified coronary artery disease. In this multicenter retrospective study, consecutive patients undergoing PCI with either Rotablation (RA) or Shockwave-intravascular-lithotripsy (IVL) were included. Primary endpoint was the impairment of coronary microvascular resistances assessed by Δ angiography-derived index of microvascular resistance (ΔIMRangio) which was defined as the difference in IMRangio value post- and pre-PCI. Secondary endpoints included the development of peri procedural PCI complications (flow-limiting coronary dissection, slow-flow/no reflow during PCI, coronary perforation, branch occlusion, failed PCI, stroke and shock developed during PCI) and 12-month follow-up adverse events. 162 patients were included in the analysis. Almost 80% of patients were male and the left descending anterior artery was the most common treated vessel. Both RA and IVL led to an increase in ΔIMRangio (22.3 and 10.3; p = 0.038, respectively). A significantly higher rate of PCI complications was observed in patients with ΔIMRangio above the median of the cohort (21.0% vs. 6.2%; p = 0.006). PCI with RA was independently associated with higher ΔIMRangio values (OR 2.01, 95% CI: 1.01-4.03; p = 0.048). Plaque modification with IVL and RA during PCI increases microvascular resistance. Evaluating the microcirculatory status in this setting might help to predict clinical and procedural outcomes and to optimize clinical results.

Rotastenting in an anomalously arising right coronary artery after an ugly dissection.

Rotational atherectomy is contraindicated in dissected coronary arteries since it can lead to progression of the dissection or perforation. In our case, the right coronary artery (RCA) arose anomalously from the left coronary sinus. The lesion in the RCA was an undilatable calcified one. There was a dissection in the RCA due to high pressure balloon dilatation. Since the patient was hemodynamically unstable and there were no options besides rotablation, we proceeded with caution. Rotablation and stenting were successfully done. Our case report highlights the importance of the need for good guide catheter support even in the presence of anomalously arising arteries and the rotablation option for unyielding calcified coronary lesions, even in the setting of a dissection.

Comparative Analysis of High-Intensity versus Low-to-Moderate Intensity Statin Therapy in Patients Undergoing Rotational Atherectomy for Calcified Coronary Artery Disease.

(1) Background: Moderate-intensity statin therapy, when compared to high-intensity statin therapy in Asian populations, has shown no significant difference in cardiovascular prognosis in small studies. The aim of this study was to compare the prognosis of patients based on statin intensity following rotational atherectomy (RA) during high-complexity percutaneous coronary intervention (PCI). (2) Methods: The ROCK registry, a multicenter retrospective study, included patients who had undergone rotational atherectomy (RA) during percutaneous coronary intervention (PCI) at nine tertiary medical centers in South Korea between January 2010 and October 2019. The patients were divided into high-intensity statin (H-statin) and moderate/low-intensity statin (M/L-statin) therapy groups. The primary endpoint includes outcomes (cardiac death, target vessel myocardial infarction (MI), and target vessel revascularization (TVR)) within an 18-month follow-up period. (3) Results: In this registry, a total of 540 patients with 583 lesions were included. We excluded 39 lesions from the analysis due to the absence of statin usage. The H-statin group had 394 lesions and the M/L-statin group had 150 lesions. There were no significant differences in baseline characteristics, procedural adverse events without heart failure history, triglycerides, or medications between the two groups. The procedural success rate showed a significant difference between the two groups. Multivariate analysis did not show a significant association between M/L-statin therapy and an increased risk of the primary endpoint. In propensity score matching analysis, no significant difference was observed in the primary endpoint either. (4) Conclusions: In high-complex RA PCI, moderate/low-intensity statin therapy is not inferior to high-intensity statin therapy in Korea.

Rota Ablation - When There is No Other Option. A Complex Case of 86 Years Old Male with Multiple Comorbids Presenting With Stemi.

The aim of this report is to explore the direct and long-term outcome in a high risk patient who was treated with rotational atherectomy (RA) to assist the placement of drug eluting stents in heavily calcified lesions. The patient presented with acute STEMI and had severely calcified Left main stem (LMS) disease, requiring plaque modification before coronary angioplasty and stent implantation. As the patient was elderly, with multiple comorbids including a number of coronary interventions, a decision of conservative management was made. Patient then re-presented with typical chest pain and pulmonary edema. A Heart Team meeting was called and high risk decision of RA to LMS was taken. His percutaneous transluminal coronary angioplasty (PTCA) to LM and LAD was planned. LMS to LAD was rotablated with 1.75 burr and PTCA with 3.5 NC at 20 Atm. During the procedure, patient developed flash pulmonary edema. In post-operative care, his renal functions deteriorated and nephrology was taken on board. After multiple sessions of hemodialysis, patient was clinically improved and stabilized. The report highlights the expertise required in RA of a complex LMS disease and judicious post-procedure care which resulted in significant reduction of morbidity, mortality and frequent hospitalizations of the patient.

Impella-Driven High-Risk Percutaneous Coronary Intervention: A Novel, Single Non-Surgical-Centre Case Report.

Complex percutaneous coronary intervention (PCI) procedures have been routinely performed in non-surgical centres in the UK for more than two decades. These procedures follow strict guidelines and recommendations by the British Cardiovascular Intervention Society to ensure a more effective running of PCI programs. Even more so, expected guiding principles necessary for the safe optimisation of complex PCI procedures have also been created.  An 81-year-old male was admitted with non-ST-elevation myocardial infarction (NSTEMI) and severely impaired left ventricle ejection fraction (LVEF; 26% according to the cardiac MRI report). Angiogram findings revealed severe multiple-vessel coronary artery disease affecting the following arteries: right coronary artery (RCA), left anterior descending artery (LAD), left circumflex artery (LCx), and intermediate artery (IM). There was also severe disease in the distal left main stem (LMS) bifurcation extending to the ostia of the LAD, LCx, and IM branches. Following a multidisciplinary meeting, the patient underwent Impella-supported high-risk PCI (complex PCI) using the DK crush technique with no peri- and post-procedure complication and a significant LV function improvement (45-49%). This is the first known case of this procedure performed at the Royal Cornwall Hospital in Treliske (RCHT), Truro, Cornwall. This case report highlights that when the decision to choose between coronary artery bypass graft (CABG) and PCI is not straightforward following an individualised risk-stratification scoring system analysis and in the setting of patient comorbidities, a high-risk PCI supported with the Impella device is a suitable alternative with promising short-term and long-term outcomes.

Evaluation of only heparin-based rota-flush solution against alternative rota-flush solution in patients with severe coronary artery calcification undergoing rotational atherectomy.

OBJECTIVE: There is limited evidence on feasibility and safety of only heparin rota-flush(OHRF)solution in rotational atherectomy (RA). We compared the safety and efficacy of OHRF solution with alternative rota-flush (ARF) solution in patients who underwent RA. METHODS: A total of 48 patients who underwent RA were enrolled in the study. In 25 patients OHRF solution and in 23 patients ARF solution was utilized. The study end points were procedural success rateandrota-related adverse cardiovascular event (RRAE) including slow flow, no reflow, bradycardia, and hemodynamic instability. RESULTS: Procedural success was achieved in all patients in both the OHRF and ARF groups. There was no statistically significant difference in RRAE between the two groups(32.0% vs. 34.7%, p = 0.83). CONCLUSION: OHRF solution appears a more simplistic solution while performing rotablation as compared to ARF solution. Side effects such as hypotension and bradycardia can be circumvented with OHRF solution during rotablation.

Retrieving entrapped guidewire using rotablation technique: case series and literature review.

Background: The present article summarizes three cases of retrieving entrapped guidewire using rotablation technique. Case summary: All three cases pertained to guidewire being fractured and entrapped during percutaneous coronary interventions (PCIs) for right coronary artery (RCA) chronic total occlusion in a local hospital. In Case 1, two fractured filaments connecting to the entrapped guidewire could be clearly seen. One filament was in the right brachial artery and the other one was in the ascending aorta. In Case 2, the operator applied buddy wire technique during PCI but forgot to withdraw the second wire before stenting. As a result, the second SION wire was entrapped by the stent and was untangled and fractured when being retrieved. In Case 3, a SION guidewire was entrapped during PCI for RCA. The initial attempt to retrieve the guidewire ended in failure. Although the entrapped guidewire was still intact, it was difficult to advance the floppy rotawire into the RCA as it was still totally occluded. In those scenarios, complete retrieval of the entrapped guidewire using catheter-based technique was hardly possible. Rotablation was used to cut the entrapped guidewire, retrieve the broken end, and leave the remnants in coronary artery jailed by the stent. Clinical and angiographic follow-up observation demonstrated that the patients were free of target vessel failure. Discussion: Entrapment of guidewire is a rare complication of PCI. The management of entrapped guidewire is usually challenging. Rotablation technique is a useful and efficient strategy when conventional methods failed to retrieve the entrapped guidewire.

Rotablation in the Very Elderly - Safer than We Think?

BACKGROUND/PURPOSE: Calcified coronary artery stenosis remains a challenge for Percutaneous Coronary Intervention (PCI). Calcium modification is facilitated by rotablation and is used in 1-3% of cases. Data on rotablation in patients ≥80 years is limited and perceived to be high risk. We compared PCI with rotablation and outcomes between patients ≥80 years and those <80 years. METHODS/MATERIALS: Retrospective analysis was performed of consecutive patients who underwent rotablation and PCI from 3 United Kingdom (UK) PCI Centres (2014-2017). In-hospital outcomes (composite of stroke, myocardial infarction, death, emergency coronary artery bypass graft surgery, vascular damage, coronary perforation, advanced AV-block, bleeding and renal impairment) and 30 day mortality risk score was compared between groups. RESULTS: 213 patients were included. 33.3% (n = 71) were ≥80 years. Baseline and angiographic characteristics were similar in the two groups. Older patients were more likely to present with acute coronary syndrome (ACS) (≥80 years 53.5% vs. 33.8% in <80 years, p = 0.006) and had increased hospital stay (≥80 years 2.8 days (±6.0) vs. 1.3 days (±1.9) <80 years, p = 0.009). Majority of PCI were performed through radial access (≥80 years 91.5% vs. 88.0% <80 years, p = 0.43). In-hospital composite outcomes were similar between the groups (≥80 years 5.6% vs. 4.9% <80 years, p = 1.0). The 30-day mortality risk score demonstrated a higher average risk of 2.5% in ≥80 years versus under 1% risk in <80 years (p < 0.001). CONCLUSION: This study demonstrates that outcomes after rotablation in the very elderly are similar to younger patients despite being high risk and presenting with ACS.

Hybrid rotablation and drug-eluting balloon strategy.

AIM: The aim was to assess the safety and efficacy of rotational atherectomy followed by drug-eluting balloon (DEB) in patients with a high risk of bleeding. METHODS: A retrospective review was carried out of hospital records of consecutive patients who underwent the hybrid procedure. RESULTS: The average age of the 23 patients was 74 years. Risk factors for bleeding included renal failure (35%), oral anticoagulation use (26%) and peptic ulcer disease (35%). All patients had procedural success. No bleeding was reported over the 24-month follow-up period. Dual antiplatelet therapy was stopped successfully in six patients (26%) at three months. Two patients had confirmed target-lesion failure (restenosis). Two patients died over the study period but the cause of death was not known to be cardiovascular disease related. CONCLUSIONS: For patients at high risk of bleeding who require rotablation, the use of a drug-eluting balloon may be a safe, effective alternative.

Rotational Atherectomy in the Management of Ruptured and Entrapped Coronary Angioplasty Balloon.

Retention and entrapment of angioplasty device fragments is a rare consequence of percutaneous coronary intervention (PCI). Due to advances in retrieval devices and introduction of new interventional techniques the need for emergency surgery has reduced significantly. There might also be clinical scenarios were remnants of retained fragments might have to be left within the coronary vessel and this might be the most appropriate option. Here we report a case of a ruptured non-compliant angioplasty balloon that was entrapped in the right coronary artery and retained in situ after multiple failed attempts at percutaneous retrieval. Medical therapy failed and hence rotation atherectomy had to be performed followed by stent implantation, there by jailing the retained fragments underneath the stent struts. To our knowledge this is the first description of rotational atherectomy of an entrapped balloon to allow for percutaneous revascularization.