BackgroundSevere coronary artery calcification increases the difficulty of percutaneous coronary intervention procedures and impairs stent expansion. Herein, we report a case of a patient who was successfully treated with rotational atherectomy using a stepped burr strategy combined with intravascular lithotripsy for plaque modification under intracoronary imaging.Case summaryA 65 year-old woman presented to our hospital with recurrent chest pain evolving for 1 year. Coronary angiography showed approximately 80% stenosis of the proximal mid-left anterior descending artery. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) revealed a 360° annular calcification. The calcification was rotablated with 1.5 and 1.75 burrs, and the lesion was undilatable with a 3.0 mm non-compliant balloon at 14 atm. Subsequently, the intravascular lithotripsy was reset for the modification of the calcified lesion. A shockwave balloon measuring 3.0 mm × 12 mm was delivered, and 40 pulses were performed at 6 atm. Intravascular imaging modalities (IVUS and OCT) revealed a circumferential calcified plaque with deep fractures. After post-balloon expansion followed by drug-eluting stent placement with a final stent expansion of 84%, there were no intraoperative complications and no major adverse cardiovascular events within 90 days postoperatively.ConclusionA combination of rotational atherectomy and intravascular lithotripsy may be an effective and complementary strategy for the treatment of severely calcified lesions that cannot be resolved using a single procedure. However, more clinical studies are required to clarify this finding.