Rotational Atherectomy Through Guide Extension Catheters: Indications, Technique, and Limitations

Abstract

Rotational atherectomy (RA) is an established technique for the treatment of heavily calcified coronary artery disease. Severe coronary calcification remains a frequent cause of procedural difficulty and device delivery failure during complex percutaneous coronary intervention (PCI). Delivery of the atherectomy burr to the target lesion may be particularly challenging in the presence of limited guide support, proximal vessel tortuosity, or unfavorable coronary anatomy that restricts safe access to distal calcified segments. Guide extension catheters (GECs) are widely used to enhance guide support and improve coaxial alignment during complex PCI. However, their use in combination with RA represents an advanced and selectively applied strategy that is not routinely addressed in conventional atherectomy training and is often avoided because of concerns regarding device interaction and difficulties during burr delivery and retrieval. Despite increasing anecdotal use in complex PCI, the technical principles and procedural safety considerations of performing RA through GECs remain insufficiently described in the literature. This review provides a focused technical overview of RA performed through GECs. We summarize the rationale for this approach, describe key technical considerations including device compatibility and burr advancement strategies, and discuss practical measures to minimize procedural complications. In addition, we outline clinical scenarios in which this technique may be beneficial, as well as situations where it should be avoided. Rather than advocating routine use, this review aims to define the role of guide extension–facilitated RA as a selective strategy for highly complex coronary anatomies.