Intravascular Plaque Modification With Rotational Atherectomy Technique for Recanalization of Heavily Calcified Chronic Total Occlusion.

objectiveWe describe a technique named the "intravascular plaque modification with rotational atherectomy" (IMAC), which provides an option for plaque modification after balloon and microcatheter failure in heavily calcified chronic total occlusion (CTO) lesions. KEY STEPS: Antegrade guidewire position was confirmed intravascularly by 3-dimensional assessment from multiple angles based on calcification or retrograde wire as a landmark. After advancing a RotaWire through the route created by the CTO guidewire, rotational atherectomy was performed on the impenetrable lesion. Either antegrade or retrograde wire crossing can be performed. POTENTIAL PITFALLS: The precise manipulation of the guidewire within the intravascular space is crucial to avoid vessel perforation. Performing rotational atherectomy subadventitially requires high expertise to avoid hematoma and rupture. RotaWire advancement through the CTO body must be slow and gentle to prevent knuckling or fracture. TAKE-HOME MESSAGE: The IMAC technique serves as an effective strategy for plaque modification to facilitate wire crossing in severely calcified CTO lesions.