Rotational atherectomy (RA) is an atheroablative technology based on differential cutting and orthogonal displacement of friction. It selectively ablates the calcified, hard, inelastic tissue while saving and preserving the integrity of non-calcified elastic tissue. It virtually eliminates the longitudinal friction between the burr and the vessel, thereby reducing the surface drag and unimpeded advancement and withdrawal of the burr. RA has proven to be a safe and established tool to effectively modify the attributes of a complex, calcified, coronary artery lesion by shaving the inelastic calcified plaque and increasing compliance during percutaneous coronary intervention (PCI) [ 1 ]. However, there is a paucity of data in the published literature about its role and safety in very elderly high-risk patients with mean age ≥80 years. Dahdouh et al. reported that RA can be safely performed in octogenarians via trans-radial approach for calcified left main coronary artery disease who were deemed high-risk candidates for surgical revascularization [ 2 ]. They enrolled 42 patients (≥80 years of age), out of whom 13 underwent RA and 29 did not. Procedural success rate was excellent in patients who underwent RA and comparable to the non-RA group. There was no significant difference in overall mortality and MACCE (major adverse cerebrovascular and cardiac events) after a mean follow-up of 25.7 ± 21.4 months in the RA group and 28 ± 32.3 months in the non-RA group. Lippmann et al. reported the findings of 29 elderly patients (mean age, 79.8 ± 8.8 years) who underwent RA for severe calcific coronary artery disease (CAD) with concomitant severe aortic stenosis. RA was safe and well-tolerated in elderly patients with severe aortic stenosis, with no intraprocedural or in-hospital stroke, myocardial infarction, death, or contrast nephropathy [ 3 ]. Chiang et al. studied 34 consecutive high-risk patients with a mean age of 77.2 ± 10.2 years, among whom 82.4% presented with acute coronary syndrome and 11.8% with cardiogenic shock [ 4 ]. Mean SYNTAX score was 50 ± 15 and EuroSCORE II scale 5.6 ± 4.8. Plaque modification with RA in PCI of heavily calcified left main coronary artery lesion was safely accomplished with a minimal complication rate and low out-of-hospital major adverse cardiac events. The angiographic success rate was 100% with a procedural success rate of 91.2%.