Introduction: Coronary artery calcification (CAC) complicates percutaneous coronary intervention (PCI) by impairing stent delivery and expansion (1). Currently, in the battle against CAC, several tools are available, which can be divided into modified balloons, atheroablative technologies, and intravascular lithotripsy (IVL) (2). Rotational atherectomy (RA) facilitates lesion modification but carries specific risks. RA of o specific lesions: ostial right coronary artery (RCA), ostial left circumflex (LCX) with substantial bending, unprotected left main, diffuse long lesions can be very challenging. Since clinical outcomes of RCA ostial lesions have been unsatisfactory for decades, RA has been a good indication for RCA ostial lesions with severe calcification (3).

Case report: Seventy-eight years old years female patient was admitted because of unstable angina pectoris. Urgent angiography showed severe calcified ostial RCA lesion. The first attempt at PCI was unsuccessful due to the lack of coaxial positioning of the guiding catheter. Finally, in a second attempt, a successful PCI RCA with single stent implantation was performed. The use of a long, 7-French femoral sheath (Destination Guiding Sheath, Terumo) was crucial for successful maneuvering and coaxial positioning of the guiding catheter. Lesion preparation was done with a 1.25 burr and non-compliant balloons (Figures 1-3).

Conclusion: Reason why RA for RCA ostial lesions are difficult are impossibility of insertion guiding catheter to RCA coaxially and difficulties keeping catheter coaxial to RCA in aorta. Also, coaxial cannot be confirmed by left oblique view which is the standard projection for RA of RCA. There is additional risk of cerebral infarction, so it is important to use small burrs to minimize the size of debris. Although it is demanding and challenging, RA has been a good indication for RCA ostial lesions with severe calcification (3).