Objectives: To compare planned versus bailout use of rotational atherectomy (RA) for plaque modification prior to stent implantation in patients with severely calcified coronary lesions.

Background: Evidence on the optimum timing of RA is scarce, although increased periprocedural complications for bailout procedures have been reported.

Methods: Procedural and one-year follow-up data from 819 consecutive patients treated with planned (n = 416) or bailout (n = 403) RA between 2008 and 2020 were analyzed. The primary cumulative endpoint was target lesion failure (TLF), defined as cardiovascular death (CVD), myocardial infarction (MI), or target lesion revascularization (TLR).

Results: Patients in the bailout group were younger, had higher prevalence of prior MI, and their target vessel was more often the right coronary artery. The prevalence of acute coronary syndrome was similar. Technical success was excellent in both groups (≥ 99 %), but fluoroscopy time and contrast volume were significantly higher in bailout RA (p < 0.001). Periprocedural complications including slow-flow, coronary dissection, and periprocedural MI were rare and comparable between planned and bailout procedures (4.8 vs 5.7, p = 0.764). Adjusted hazard ratios showed a tendency for higher TLFs in the planned approach (HR 1.39 [0.97-1.99], p = 0.074), which was driven by TLR (HR 1.62 [1.03 – 2.55], p = 0.038), but neither by CVD (HR 0.80 [0.42, 1.53], p = 0.498), nor by MI (HR 0.97 [0.42-2.26], p = 0.946). All-cause mortality was similar (HR 1.16 [0.68 – 1.96], p = 0.586). 

Conclusions:RA was efficient and resulted in a TLF-free event rate in the majority of patients. Bailout RA was safe and not associated with worse periprocedural or long-term outcome in a high-volume center. Confirmation in a prospective, randomized trial is needed