It has a limited role in facilitating the dilation or stenting of lesions that cannot be crossed or expanded with PCI.520,521 Devices for directional coronary atherectomy are no longer marketed in the United States. 5.5.2. Thrombectomy: Recommendation Class IIa 1. Aspiration thrombectomy is reasonable for patients undergoing primary PCI.522 524 (Level of Evidence: B) The benefit of thrombectomy in patients with STEMI appears to be dependent on the type of thrombectomy technique used.522 526 No clinical benefit for routine rheolytic throm- bectomy (AngioJet device, MEDRAD Interventional, Minne- apolis, MN and Pittsburgh, PA) has been demonstrated in support the use of manual aspiration thrombectomy during primary PCI to improve microvascular reperfusion and de- crease MACE. It is not known whether a strategy of selective thrombus aspiration in patients with a large thrombus burden might be equivalent to routine thrombus aspiration. 5.5.3. Laser Angioplasty: Recommendations Class IIb 1. Laser angioplasty might be considered for fibrotic or moderately calcified lesions that cannot be crossed or dilated with conventional balloon angioplasty.527 (Level of Evidence: C) Class III: NO BENEFIT 1. Laser angioplasty should not be used routinely dur- ing PCI.516,518,528 (Level of Evidence: A) RCTs of laser angioplasty have not demonstrated improved clinical or angiographic PCI outcomes, although some prac- titioners think that laser angioplasty may be of use in the treatment of lesions that are difficult to dilate with balloon 5.5.4. Cutting Balloon Angioplasty: Recommendations Class IIb 1. Cutting balloon angioplasty might be considered to avoid slippage-induced coronary artery trauma dur- ing PCI for in-stent restenosis or ostial lesions in side branches.529 (Level of Evidence: C) Class III: NO BENEFIT 1. 