Rotational atherectomy is contraindicated in the presence of coronary dissection. Clinical scenarios of coronary dissection in which rotational atherectomy offers the only option are rare but can occur. This case study presents a challenging circumstance of an extensive coronary dissection resulting from failed angioplasty of a resistant and undilatable lesion. Rotational atherectomy was used as a last resort when the patient became clinically unstable. Standard technique of rotational atherectomy and additional technical considerations for this uncommon but potentially devastating scenario are discussed.