ROBITAL Atherectomy via 5-F Guide for Calcified Left Main Disease With Cardiogenic Shock.

BACKGROUND

Sequential ROtational and orBITAL (ROBITAL) atherectomy combines sequential rotational and orbital atherectomy to manage complex coronary calcium. We report its feasibility using a 5-F guiding catheter in a patient with critical left main (LM) disease when larger guides could not achieve stable engagement.

CASE SUMMARY: An 83-year-old woman presented with cardiogenic shock, pulmonary edema, and severe calcified ostial/distal LM disease. After intra-aortic balloon pump insertion, only a 5-F JL 3.5 guide achieved coaxial engagement. ROBITAL atherectomy allowed adequate calcium modification, allowing intravascular ultrasound-guided percutaneous coronary intervention. She recovered fully and remained well 3 years later.

DISCUSSION: Limited literature supports 5-F calcium modification strategies. This case demonstrates ROBITAL atherectomy via a 5-F guide for unstable LM disease when larger guides failed to engage the LM.

TAKE-HOME MESSAGE: ROBITAL atherectomy enables complex calcium modification through a 5-F guiding catheter, extending options for patients with only limited radial access and when larger guides cannot engage the coronaries.