Rotational atherectomy in the subadventitial space to allow safe and successful chronic total occlusion recanalization: Pushing the limit further

Dissection and re-entry (DR) techniques have played a key role in the increase of success rates of chronic total occlusion (CTO) recanalization. DR usually allows wiring complex occlusions, even in case of important calcification. In extreme cases, such as in balloon failure-to-cross, rotational atherectomy (RA) might be decisive. However, according to experts' recommendations, RA should not be performed in dissection planes because of the high risk of perforation and further extending the dissection, so that its use after DR might be limited. Here, we describe a case of successful right coronary artery CTO recanalization in which, after failure of several antegrade and retrograde techniques, RA was safely performed antegradely in the subadventitial space, thus eventually enabling reverse controlled antegrade and retrograde subintimal tracking (CART). Although the feasibility of RA in CTO percutaneous coronary intervention had already been suggested, this case reports on the novel use of RA to allow further manipulation of the subadventitial space (reverse CART) prior to successful recanalization.