New Frontiers for Orbital Atherectomy-Crossing an Uncrossable Chronic Total Occlusion

Managing chronic total occlusions (CTOs) in coronary artery disease remains a significant challenge, especially in cases where standard techniques fail to cross the lesion. Uncrossable lesions are rare but require innovative strategies for successful treatment. Orbital atherectomy, traditionally used for calcified plaques, may offer a solution in these cases. We present the case of a 62-year-old male with exertional chest pain and a CTO in the right coronary artery (RCA). The patient had a positive stress echocardiogram for inducible ischemia despite optimized medical therapy. Multiple conventional techniques, including ballooning, microcatheter use, and laser atherectomy, failed to cross the proximal cap of the CTO. After these methods proved ineffective, orbital atherectomy using the DiamondBack 360 system successfully crossed the lesion and enabled subsequent balloon angioplasty and stenting. This may be the first reported case where orbital atherectomy was used after the failure of laser and other techniques. The case highlights the role of orbital atherectomy in the treatment of uncrossable CTOs, expanding its application beyond calcified lesions. The versatility of this technology, particularly when other methods fail, underscores its importance as an adjunctive tool in complex PCI. In conclusion, orbital atherectomy should be considered a valuable option for crossing uncrossable coronary CTOs, especially when standard and advanced techniques, including laser atherectomy, fail. This case broadens the scope of its use in coronary intervention, providing a new perspective on tackling resistant lesions.