Blunt microdissection and rotational atherectomy: an effective combination for the resistant chronic total occlusion

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) has a lower success rate than nontotal occlusions. Like nontotal coronary occlusions, successful procedural outcomes of CTOs confers improvement in clinical outcomes. Reasons for unsuccessful PCI of CTOs may stem from various steps of the procedure including failure to cross the occlusion with a guidewire or a balloon, or failure to adequately dilate or modify the lesion. The Frontrunner blunt microdissection device is designed to improve the odds of guidewire passage through coronary occlusions, whereas the Rotablator rotational atherectomy device is intended for plaque modification, especially in resistant, elastic or calcific lesions. The Frontrunner and Rotablator can each facilitate the procedure at their respective junctures; the combined use of these technologies can enhance the overall PCI success rates, especially regarding difficult CTOs. This case presentation encounters two technical challenges: the inability of the balloon catheter to cross the CTO, and the inability to recross the occlusion with the less favorable RotaWire. In this case, the combined use of the Frontrunner and Rotablator devices was necessary to achieve overall procedural success. When tackling difficult CTOs, a comprehensive strategy that encompasses multiple devices and technologies can enable ultimate procedural success.