Severe coronary artery calcification (CAC) remains challenging during percutaneous coronary intervention (PCI) and often requires one or more advanced calcium modification tools. We describe the combination use of rotational (RA) or orbital atherectomy (OA), with intravascular lithotripsy (IVL), termed Rotatripsy and Orbital-tripsy respectively, for modifying CAC prior to stent implantation during PCI.

Weperformed a retrospective analysis of patients treated with Rotatripsy orOrbital-tripsy at our center between July 2019 and March 2022. The primaryefficacy endpoint was procedural success (successful stent implantation,<30% residual stenosis visually, thrombolysis in myocardial infarction 3flow; absence of types C to F dissection/perforation or loss of side branch≥2.0mm visually) without in-hospital major adverse cardiovascular events (MACE,cardiovascular death, myocardial infarction [MI], target-vessel revascularization). 
Following coronary angiography showingsignificant CAC and decision to proceed with PCI at the discretion of theinterventional cardiologist, intravascular imaging was performed. Opticalcoherence tomography (OCT) was performed with the Dragonfly Optis^TMsystem (Abbott Vascular, SantaClara, CA, USA) and optical frequency domain imaging (OFDI) with the FastViewcatheter connected to the Lunawave® system (Terumo, Tokyo, Japan). Intravascularultrasound (IVUS) was performed with the Altaview catheter connected to theVISICUBE system (Terumo, Tokyo, Japan).  

A totalof 25 patients were included in our study (14 Rotatripsy and 11 Orbital-tripsy).The mean age was 72.2 ± 7.6 years and 76% were men. PCI was guided byintravascular imaging in 24 patients (96%). All cases were treated with either RA or OA before utilization of IVL. Procedural success was achieved in 22 cases (88%) with one side branch loss without peri-procedural MI (4%) and 2 in-patient deaths (8%) unrelated to the procedure (one intracranial hemorrhage and one cardiac arrest).

Patient Characteristics	Patients (n=25)
Age, yrs. ± SD	72.2 ± 7.6
Male	19 (76.0)
Hypertension	23 (92.0)
Diabetes	18 (72.0)
Dyslipidemia	18 (72.0)
Previous stroke or TIA	3 (12.0)
Smoking history	9 (36.0)
Prior PCI	12 (48.0)
Chronic kidney disease (eGFR <60mls/min/1.73m2) ·       Long-term dialysis	11 (44.0) 3 (12.0)
Presentation ·       Stable ischemic heart disease ·       Acute coronary syndrome	19 (76.0) 6 (24.0)

We describe efficacious use of both Rotatripsy and Orbital-tripsy to modify severe CAC during PCI in a real-world setting. Intravascular imaging can guide appropriate use of these devices to complement each other to modify severe CAC to achieve optimal outcomes.