BACKGROUND Revascularization of patients with heavily calcified coronary arteries can be a challenge for interventional cardiologists. The procedural success rate in these patients can be improved by using rotational atherectomy (RA). OBJECTIVE To compare in-hospital outcomes and those at 12-month follow-up between patients who underwent RA as a bailout procedure secondary to failed conventional angioplasty or as an elective procedure. METHODS This is a retrospective analysis of 156 consecutive patients hospitalized at a high-volume percutaneous coronary intervention (PCI) center who underwent RA. In 43 (27.6%) patients, RA was performed on an elective basis (group 1). In 113 (72.4%) patients RA was carried out after unsuccessful traditional angioplasty (group 2). RESULTS Patients in group 1 more often had a history of peripheral vascular disease (32.6% vs. 15.9%; p = 0.03). Group 1 was dominated by patients with multivessel disease (62.8% vs. 33.6%; p < 0.001). The left main coronary artery was more often treated in group 1 (25.6% vs. 2.7%; p < 0.001). Success rates in the two groups were similar: 93.0% for group 1 and 91.2% for group 2 (p = 0.71). The rate of in-hospital complications did not significantly differ between the groups. Twelve-month MI, TLR, and TVR rates were similar in both groups. There was no difference in the 12-month survival rate (86.1% vs. 92.0% in group 2; p = 0.27) or MACE (16.3% vs. 15.0%; p = 0.8). CONCLUSIONS Rotational atherectomy is associated with high efficacy and a relatively low risk of complications, with no significant differences in outcomes between patients treated with primary and secondary RA procedures.