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83 yr M with worsening exertional dyspnoea and chest pain for past 6 months. Background: Heart failure with preserved ejection fraction and moderate mitral regurgitation, COPD - ex-smoker, Atrial Fibriallation, Hypertension, Hypothyroidism 

 Hb 114 Platelet count 185, eGFR 60, Cr 92 umol/L , BNP 301 ng/L TTE - normal LV size and function EF 57%, Normal RV size and function, RVSP 26mmHg, Biatrial dilatation, Grade 2-3/4 MR, Grade 1/4 AR , Grade 1/4 TR 

Initial diagnostic angiogram showed no significant disease and LAD and LCx. Heavily calcified severe proximal RCA and mid RCA disease with calcium nodules for staged PCI to RCA 

7Fr AL 0.75 guided was used via 7Fr sheath in right femoral artery. Temporary pacing was inserted upfront. Wired proximal RCA lesion with Fielder XT-A using Turnpike LP microcathter but unable to cross mid RCA lesions . Used Fielder XT-A,  Fileder XTR, Gaia second, Hornet 14 wires but wires were damaged. Mid RCA lesion was crossed with Fielder XTR but microcatheter was uncrossable. Sapphire 0.85 x 10 balloon was used but still uncrossable. Changed microcatheter to Turnpike Spiral 135cm and changed Fielder XTR to Rotawire Drive 0.009 x 330. RotaPro  Burr 1.5 was used and  rotaablation was performed (15 passes and 190 sec total). Even after rota, IVUS was unable to cross mid RCA. Rota 2.0 Burr was used for 55 secs and 4 passes. NC 3.5 x 12 was used as predilatation balloon.  After that, lesions were assessed using IVUS. Drug eluting stents -  4 x 38 in mid RCA and 4 x 38 in proximal RCA were deployed. NC 4 x 15 was used for postdilatation. IVUS showed stents were well-expanded and well-apposed  and no dissection. 

Calcified lesions are very challenging and needs to know how to choose appropriate calcium modification tools and  use intravascular imaging to achieve best result This case also showed step-by-step management of wire crossable device uncrossable lesion