Rotational and orbital atherectomy: a Cath Lab 101 guide

Reviewed by Rodnie Oro, cath lab charge nurse · Last reviewed: October 2026 · Education only, not medical advice

Coronary atherectomy in one minute

What it is: a technique used during PCI where a tiny spinning tip sands down hard, calcified plaque inside a heart artery, so a balloon and stent can open it properly.

Who it is for: people having PCI whose narrowing is too hard for a balloon to open or for a stent to expand fully.

Main risks: those of PCI, plus a higher chance of slow flow, artery tear or perforation; rhythm problems; rarely heart attack or emergency surgery.

Usually: under local anaesthetic, 1–2 hours, home the same or next day.

On this page: What is coronary atherectomy? · Who is it for? · When is it done? · Step by step · Recovery · Risks · Kit list · First time in the lab? · FAQ

A spinning tip modifies calcified plaque before stenting.

What is coronary atherectomy?

Over time, plaque in a heart artery can become calcified, hard like bone. A balloon may not open it, and a stent may not expand fully.

Atherectomy modifies the calcium before ballooning and stenting:

• Rotational atherectomy: a small diamond-coated burr spins at very high speed on a special wire, grinding calcium into tiny particles that wash away in the blood
• Orbital atherectomy: a diamond-coated crown orbits as it spins, sanding the artery wall

It is always part of a PCI. Imaging inside the artery (IVUS or OCT) is often used to see the calcium.

New to the acronyms? See the Cath Lab Abbreviations A–Z.

Who is it for?

It may be considered for people with:

• heavily calcified narrowings seen on angiogram or intravascular imaging
• narrowings that a balloon cannot cross or open
• planned PCI where the team expects poor stent expansion

The decision is made by your heart team, who will talk through the reasons, the alternatives and the risks with you.

When is it done?

It can be planned in advance or done urgently. Before it, you usually have:

• blood tests, including kidney function and blood count
• an ECG, and often an echo or other scan
• a review of your medicines, especially blood thinners and diabetes medicines, as per centre protocol
• a chance to ask questions and give consent

Step by step

1. Getting ready

You lie on the X-ray table. The wrist (or groin) is numbed with local anaesthetic. ECG, blood pressure and oxygen levels are monitored. You may be given medicines to thin the blood, as per centre protocol.

2. Access

A sheath is placed in the radial artery at the wrist or the femoral artery in the groin, sizes per device and operator. A guide catheter is placed at the opening of the coronary artery and heparin is given, dose as per centre protocol. A thin guidewire is passed across the narrowing.

3. Atherectomy

• A. Special wire. The guidewire is exchanged for a dedicated atherectomy wire.
• B. Device advanced. The burr or crown is advanced to just before the narrowing.
• C. Short runs. Several short runs sand down the calcium while flow is watched.
• D. Balloon and stent. The artery is prepared with balloons and then stented.

You may feel chest discomfort while a balloon or device is in the artery. Tell the team; it usually settles quickly.

4. Finishing

A final angiogram checks the result. The sheath is removed and the wrist closed with a pressure band, or the groin with pressure or a closure device, per device and operator.

Recovery and aftercare

• First hours: checks of the wrist or groin, heart rhythm and blood pressure, as per centre protocol.
• Going home: often the same or next day.
• Medicines: take your blood thinners exactly as prescribed; don't stop them without talking to your heart team.
• Activity: avoid heavy lifting with the treated arm or leg for a few days.
• Driving: the DVLA rules depend on your condition; ask your team.
• Follow-up: clinic review and cardiac rehabilitation where offered.

Call 999 if you have chest pain, breathlessness, fainting, signs of a stroke, or heavy bleeding or swelling at the access site.

Risks and complications

Your team will explain the risks that apply to you. Possible problems include:

• bruising or bleeding at the wrist or groin
• damage to the treated artery, such as a tear (dissection) or, rarely, a perforation
• debris or clot travelling downstream, causing chest pain or a small heart attack
• heart rhythm problems
• kidney effects from contrast dye
• heart attack, emergency surgery, stroke or death (rare)

Cath lab kit list (printable)

Barts example kit list

An example from one UK centre, written generically. Every lab has its own protocol, and sizes and doses vary.

• radial or femoral arterial sheath, size per device and operator
• guide catheter, shape per operator
• coronary guidewire(s), per operator
• PCI kit (Y-connector, inflation device and accessories)
• heparin, as per centre protocol
• atherectomy system with dedicated wire, burr or crown size per device and operator
• flush solution as per centre protocol
• temporary pacing available, as per centre protocol
• balloons and stents, sizes per device and operator
• IVUS or OCT, per operator

Procedural steps (Barts example)

• Access; guide; angiogram
• Imaging to assess calcium
• Wire exchange to the atherectomy wire
• Device set-up and test outside the body
• Short runs with flow and pressure monitored
• Balloon preparation, stent, post-dilatation; final imaging

First time in the cath lab?

💡 First-time tip

• Watch the pressure. Call out any drop in blood pressure during runs.
• Pacing nearby. Slow heart rates can occur, especially in the right coronary artery.
• Short runs. The operator keeps each run short; time them.
• Flush running. Check the flush bag is connected and not empty.

FAQ

Does it hurt?

You may feel chest discomfort or a buzzing sensation during runs.

Does it replace a stent?

No. It prepares the artery for a balloon and stent.

Is it common?

It is used in a minority of PCIs with heavy calcium.

Related Cath Lab 101 guides

• PCI (coronary angioplasty and stents)
• Coronary angiogram
• Chronic total occlusion (CTO PCI)
• Cath Lab Abbreviations A–Z

Sources

All checked on 10 October 2026. Each page's own date is shown where it gives one.

• Knuuti J, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020;41(3):407–477. PubMed 31504439
• Byrne RA, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023;44(38):3720–3826. PubMed 37622654
• StatPearls (NCBI Bookshelf), search: rotational atherectomy. ncbi.nlm.nih.gov/books

Disclaimer

Education only. This page is for general education for healthcare students, cath lab staff and curious readers. It isn't medical advice and doesn't replace advice from your own doctor, heart team or local unit protocols. Equipment and medicines are described generically. No product or manufacturer is recommended. If you think someone is having a heart emergency, call 999.

Disclosure: I work for a company that makes a device used in this procedure. This page is independent education, isn't sponsored or reviewed by any company, and doesn't recommend any product.

All diagrams on this page are original illustrations created for rodnieoro.com.