Making Rotational Atherectomy in Acute ST-elevation Myocardial Infarction Safer

Rotational atherectomy (RA) is usually avoided in ST-elevation myocardial infarction (STEMI) and tortuous coronaries as it may increase the risk of no-reflow and coronary perforation. This case reports the successful use of RA in an 80-year-old patient with acute anterior STEMI with calcified left anterior descending artery with an acute bend. RA was done initially with a small burr of 1.25 mm at 150,000 rotations per minute, upsized subsequently to 1.5 mm at 160,000 rotations per minute. After lesion preparation, stenting was done with excellent final result. RA can be done in acute STEMI with calcified culprit lesion as a last resort with excellent outcomes. Pretreatment of these patients with antiplatelets, statins, glycoprotein IIb IIIa inhibitors, and starting with a smaller burr, keeping the burr speed relatively low and burr time shorter, can reduce the incidence of no-reflow which is such a dreaded complication of RA, especially in acute coronary syndrome settings.