Intervention was performed on the LAD as this was most likely the culprit lesion producing symptoms at rest and to stage and do FFR-guided PCI of the RCA later. In planning the procedure, the specific challenges in this case were:

Arterial access was obtained with 6F right radial approach. A 6F XB3 guide was used. The lesion was crossed initially with BMW wire and Fielder wire into the jailed LAD and its major side branch, respectively. Attempts to cross into the jailed LAD with multiple balloons including Neich Sapphire II 2.0 × 15; 1.0 × 10 mm and TriReme Glider 1.5 × 8mm were unsuccessful (Fig. 26.3). We decided to cross with a Finecross microcatheter and change the strategy to rotablation of the stents. The Finecross could not cross despite adequate guide catheter support (Fig. 26.4). The lesion was then crossed directly with the extra-support Rotawire with the Finecross microcatheter wedged at the lesion (Video 26.2). Rotablation with a 1.25 mm burr was performed at 150,000 RPM along with the use of Rotaglide solution (Fig. 26.5). The stents could be successfully crossed with the 1.25 mm burr after nine rounds of drilling with each round lasting for about 20 s (Fig. 26.6, Video 26.3).