Abstract
BACKGROUND: Radial artery access is the preferred route for percutaneous coronary intervention; however, severe calcification may prevent sheath and catheter advancement, particularly in patients with diffuse peripheral artery disease. CASE SUMMARY: A 74-year-old man with multiple cardiovascular risk factors was referred for left anterior descending artery percutaneous coronary intervention. The right radial artery was the only conventional access due to bilateral femoral artery disease and prior left radial occlusion. After successful puncture, catheter advancement was impeded by dense proximal radial calcification. After failure of conventional techniques, rotational atherectomy was performed within the radial artery, enabling successful lesion crossing and procedural completion. DISCUSSION: The decision to perform radial rotational atherectomy, rather than crossover to another vascular access, was driven by the absence of safer alternatives. Although established for coronary calcified lesions, this technique has not been described for radial access preparation. Intravascular ultrasound confirmed multiple calcium fractures and adequate luminal expansion without clinically significant vascular injury. TAKE-HOME MESSAGE: Radial rotational atherectomy may represent a controlled bailout strategy to preserve the safest vascular access when standard approaches fail.