Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics: update 2026

Figures

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  Fig. 1. . How to cut and pull the drive shaft sheath. Panel A: A RA burr (1.25-mm) was inserted into a 6-Fr guide catheter via a Y connector. Panel B, C: The drive shaft, drive shaft sheath, and RA wire were cut together near the advancer. Panel D, E: The drive shaft sheath was pulled back and removed. Panel F: After the drive shaft sheath was removed, the drive shaft remained in the same position. Panel G, H: A guide wire (0.014 inch) passed through the guide catheter via an inserter and Y-connector. Panel I: A 2.5 × 15 mm conventional balloon easily passed through the guide catheter. This figure was reproduced with the permission from Sakakura, et al. [198]

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  Fig. 2. Flow chart for burr entrapment. Abbreviations: DS, drive shaft; DSS, drive shaft sheath; GW, guidewire. This figure was reproduced with the permission from Ogawa, et al. [207]

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  Fig. 3. Management strategy for rotablator tip fractures. This figure was reproduced with the permission from Kaneko, et al. [120]

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  Fig. 4. Management strategy for rotablator driveshaft fractures. This figure was reproduced with the permission from Kaneko, et al. [120]

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  Fig. 5. Why RA to ostial RCA is difficult?

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  Fig. 6. Schema of two types of perforation in LCX ostial lesions with substantial bending

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  Fig. 7. Schema of conventional and halfway rotational atherectomy Panels (A), (B), and (C) illustrate the conventional rotational atherectomy, whereas panels (D), (E), and (F) illustrate the halfway rotational atherectomy. (A): The burr positioned just before the calcified lesion. (B): The burr ablated the proximal segment of the calcified lesion. (C): The burr ablated the full segment of the calcified lesion. (D): The burr positioned just before the calcified lesion. (E): The burr ablated the proximal segment of the calcified lesion. (F): Balloon dilatation was performed for the rest of the calcified lesion. This figure was reproduced with the permission from Sakakura, et al. [168]

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  Fig. 8. Representative illustration of halftime rotational atherectomy. Panel A. Rotational atherectomy (RA) to a diffuse long lesion is performed. Panel B. A marked ST-segment elevation is observed during RA. The burr is in the middle of the lesion. Panel C. The RA system including the burr is pulled out from the guide catheter. An operator takes a halftime until ST resolution. Intracoronary vasodilators such as nitroprusside can be injected. If coronary flow is fully recovered, an operator can select different approaches (Panels D, E, F). Panel (D) The burr-size down is a standard approach for diffuse long calcified lesion. Panel (E) The exchange of RotaWire is also a standard approach for diffuse long calcified lesion. Panel (F) The restarting RA with same burr and same RotaWire is a unique approach for diffuse long calcified lesion. This approach does not require additional cost. This figure was reproduced with the permission from Sakakura, et al. [169]

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  Fig. 9. Algorithm: When operators felt difficulty in RA for diffuse long calcified lesions