Triple-Sequence Rotational-Orbital-Rotational Atherectomy for a Heavily Calcified Left Main Bifurcation

Heavily calcified left main trunk bifurcation lesions remain challenging in percutaneous coronary intervention. An 82-year-old man presented with exertional dyspnea. Angiography revealed a heavily calcified distal left main trunk involving the left anterior descending artery and left circumflex artery. Intravascular ultrasound demonstrated circumferential calcification with a >270°arc. Triple-sequence rotational-orbital-rotational atherectomy (RA-OA-RA) was performed. The first RA created a bilobular lumen; OA enhanced wire bias toward the calcified arc; and the second RA generated an oval shape, enabling optimal stent expansion without burr upsizing. This represents the first intravascular ultrasound-validated RA-OA-RA sequence demonstrating stepwise morphological transformation.