Rotational Atherectomy (Rotablator) in Complex Calcified Coronary Lesions: Current Evidence and Clinical Applications

Rotational atherectomy is a fundamental tool in the management of complex calcified coronary lesions, particularly in cases in which conventional balloon angioplasty is insufficient. These lesions, which are common in older patients and in those with comorbidities such as diabetes mellitus, chronic kidney disease, hypertension, and dyslipidemia, are associated with greater anatomical complexity, reduced vascular compliance, difficulty achieving adequate stent expansion, and poorer clinical outcomes. The pathophysiology of coronary calcification involves active processes such as osteogenic differentiation, inflammation, and metabolic disturbances, all of which have direct implications for lesion rigidity and the success of percutaneous coronary intervention. In this setting, assessment with intravascular imaging, particularly intravascular ultrasound and optical coherence tomography, is essential to characterize the distribution, depth, and severity of calcium and to guide the selection of plaque modification strategies. Rotational atherectomy works through differential ablation of calcified tissue and requires careful technical execution, including appropriate burr selection, controlled rotational speed, and adjunctive pharmacologic support. Available evidence demonstrates high procedural success rates, although the technique is also associated with a higher incidence of complications such as slow flow, no-reflow, coronary perforation, distal embolization, and burr entrapment. In contemporary practice, its integration with complementary techniques such as intravascular lithotripsy, together with the increasing use of imaging-guided algorithms, has expanded its utility in complex scenarios and reinforced its role within an increasingly individualized and technically precise interventional approach.