We approached the RCA first. IABP was inserted via left femoral arterial access. A temporary pacing wire was placed in the right ventricular apex. A 6F JR4 guide was used to engage the RCA. The plan was to perform rotablation given the extensive calcified disease. A standard 0.014″ guidewire was placed in the distal RCA into the right posterolateral branch. Using a Finecross microcatheter, this was exchanged for a rota extra-support wire. Rotational atherectomy with a 1.25 mm burr at 150,000 rpm was performed all the way to the right posterolateral branch (Figs. 17.3 and 17.4 and Videos 17.3 and 17.4). This required gentle technique as well as advancement of the rota sleeve forward to allow sufficient reach of the burr distally. After rotational atherectomy, the rota wire was exchanged for standard guidelines. Balloon angioplasty followed by sequential DES placement was performed. The final angiographic result was satisfactory with TIMI 3 flow (Figs. 17.5 and 17.6 and Videos 17.5 and 17.6).