ROBITAL Technique: Combination of Sequential ROtational and orBITAL Atherectomy in Management of Complex Coronary Calcium.

BACKGROUND & AIMS: Heavily calcified coronary artery disease remains one of the most formidable challenges in contemporary percutaneous coronary interventions, often leading to suboptimal stent expansion, procedural complications, and poor long-term outcomes. Over the years, a wide range of calcium modification techniques have been developed, including cutting and scoring balloons, rotational atherectomy, orbital atherectomy, high-pressure balloons, intravascular lithotripsy, and laser atherectomy, each with unique mechanisms, strengths, and limitations. This article aims to provide a comprehensive overview of these established and emerging calcium modification strategies, highlighting their roles in complex lesion preparation. It also introduces the ROtational orBITAL atherectomy (ROBITAL) technique, a novel sequential approach that combines rotational atherectomy followed by orbital atherectomy.

METHOD & RESULT: Using rotational atherectomy to create an initial lumen, the technique then facilitates orbital crown delivery for more uniform and extensive plaque modification. We illustrate the rationale, technical considerations, and clinical application of the ROBITAL approach, including its use in complex left main bifurcation lesions.

CONCLUSION: This evolving strategy expands the armamentarium of calcium modification techniques, offering a safe, efficient, and potentially cost-effective solution for high-risk and heavily calcified coronary lesions.