Primary Orbital Atherectomy for Treating a Heavily Calcified Balloon-Uncrossable Lesion

Balloon uncrossable lesions are common and can be challenging to treat. The most commonly used initial treatment strategies are using a small balloon (occasionally intentionally rupturing it) and increasing guide catheter support. Atherectomy can be challenging to perform in this setting, as the insertion of an atherectomy guidewire requires crossing the lesion with a microcatheter or over-the-wire balloon, which often fails. We report the use of the ViperWire Advance flex tip guidewire (Cardiovascular Systems, Inc., St. Paul, Minnesota) for primary wiring of a heavily calcified balloon uncrossable lesion, followed by orbital atherectomy and successful equipment crossing leading to procedural success.