Background Rotational Atherectomy has become increasingly utilised over the past decade. Although a relatively safe procedure in appropriately trained physicians’ hands, there are a number of recognised complications. Case Summary We describe the case of a 64-year-old female who presented with chest pain and was diagnosed with non-ST-segment elevation acute coronary syndrome. A Transthoracic Echocardiogram (TTE) showed normal biventricular function and no valve disease. Invasive coronary angiogram was performed which revealed a severely calcified ostial right coronary artery (RCA) disease which was felt to be the culprit of the presentation. Balloon dilatation was unsuccessful therefore rotational atherectomy with an AL 0.75 guide and a 1.5 mm Rota-Burr was utilised and improved calcium burden. This was complicated by ostial dissection, treated with stenting. A TTE following the procedure revealed moderate aortic regurgitation (AR). The patient was discharged as she remained asymptomatic. An outpatient transoesophageal echocardiogram performed eight months later showed evidence of severe eccentric AR. Cardiac magnetic resonance imaging confirmed severe AR with left ventricular dilatation. Repeat angiogram 10 months after index procedure revealed in-stent restenosis and the patient was accepted by heart multidisciplinary team for aortic valve replacement and grafting of RCA. Discussion As the field of RA continues to expand, we propose that novel complications such as reported in this case may become recognised. Finally, we stress the importance of multi-modality imaging in the investigation and timely planning of interventions in the management of these patients.

<b><i>Introduction:</i></b> Peritoneal dialysis (PD) remains underutilised in the West. The proportion of patients in the UK starting renal replacement therapy (RRT) with PD fell from 7.2% in 2011 to 6.0% in 2016. At our centre, 8.4% of dialysis patients received PD in April 2014. Evidence suggests that home dialysis improves patient clinical outcomes; therefore, a target was agreed to achieve 25% of dialysis patients receiving PD by 2018. <b><i>Methods:</i></b> A rapid improvement process was introduced, as a quality improvement tool, to increase and sustain the PD programme. With multidisciplinary team support for PD growth, a nephrologist was trained to insert PD catheters. Nurses were trained to provide patients with balanced pre-dialysis information and discuss alternative dialysis modalities with haemodialysis (HD) patients. The “Acceptance, Choice and Empowerment” project raised awareness of home therapy choices, using a peer educator model specifically for ethnic minority patients. Lean methodologies were used to ensure continuous quality improvement. <b><i>Results:</i></b> PD uptake increased from 37 to 84 patients, giving a PD penetration increase from 8.4% to 19.1% between April 2014 and March 2018. Catheter insertions increased from 94 at the end of QI Period 1 to 185 at the end of QI Period 2, representing a 97% increase, with the medical/surgical split remaining stable. Peritonitis rates remained stable, and PD drop off to HD reduced from 52% to 41% during the same period. <b><i>Conclusions:</i></b> By implementing a rapid improvement process and embedding a quality improvement programme, the number of incidents and prevalent PD patients increased and was sustained.