Comprehensive Optical Coherence Tomography–Guided RotaTripsy for Massive Coronary Calcified Nodule: A Decision-Making Approach

Objectives: We aim to describe the step-by-step optical coherence tomography–guided rotational atherectomy and intravascular lithotripsy for treating substantial coronary calcified nodules. Key Steps: These include initial rotational atherectomy with a 1.5-mm burr, multiple optical coherence tomography imaging studies to assess lesion morphology, upsizing the rotational burr to 2.0 mm for further debulking, performing adjunctive intravascular lithotripsy with a 3.5-mm Shockwave balloon (Shockwave Medical Inc), and final stent deployment and optimization. Potential Pitfalls: Potential complications include burr entrapment during rotational atherectomy, inadequate lesion modification with initial rotational atherectomy, and failure to achieve deep calcium fractures leading to stent underexpansion. To avoid these complications, start with a smaller burr size and use a slow pecking motion, conduct a meticulous intravascular imaging assessment, and upsize the burr and adjunctive intravascular lithotripsy on the basis of 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.