Feasibility and safety of orbital atherectomy in uncrossable lesions

To the Editor, Orbital atherectomy (OA) is a technique designed to treat non-dilatable calcified lesions in coronary arteries using the Diamondback 360 device (Abbott, United States), which consists of a 1.25 mm diamond-coated crown that enables bidirectional lesion treatment through a dual mechanism by combining centrifugal force (creating elliptical orbits) and surface abrasion to modify the calcified plaque.1 Intracoronary imaging is recommended if severe calcified lesions are suspected; several characteristics guide the use of plaque modification techniques. In summary, the “rule of 5” can be adopted: lesions in which calcium occupies > 50% of the circumference, extends > 5 mm longitudinally, and has > 0.5 mm thickness require advanced calcium modification techniques. A wide range of techniques currently exist for treating calcified lesions, including atherectomy systems such as rotational atherectomy (RA) and OA, specialized balloons (intravascular lithotripsy, cutting balloons, scoring balloons, high-pressure balloons, etc.), as well as excimer laser coronary atherectomy (ELCA). Each has advantages and disadvantages. In cases of deep calcium layers, OA or intravascular lithotripsy (IVL) balloons may be preferred, while for superficial calcium, RA and OA are generally used.2 The recently published ROLLER-COASTR study compared RA, IVL, and ELCA in calcified coronary disease based on stent expansion assessed by optical...