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.