Limited data are available on the effect of rotational atherectomy plus stenting versus rotational atherectomy plus balloon angioplasty for complex coronary lesions. We compared the early and late clinical outcomes between rotational atherectomy plus stenting (158 patients, 171 lesions) and rotational atherectomy plus balloon angioplasty (165 patients, 186 lesions) for complex lesions. Baseline characteristics were similar between the two groups. The procedural success rate was similar between the 2 groups (94% in rotational atherectomy plus stenting versus 96% in rotational atherectomy plus balloon angioplasty; p = 0.54). There were no significant differences in the in-hospital complications between the 2 groups. During mean follow-up of 40.4 +/- 20.2 months, fourteen patients died: 6 in rotational atherectomy plus stenting and 8 in rotational atherectomy plus balloon angioplasty. Target lesion revascularization was similar between the 2 groups (20% in rotational atherectomy plus stenting versus 24% in rotational atherectomy plus balloon angioplasty; p = 0.46). Three-year event (death, nonfatal myocardial infarction and target lesion revascularization)-free survival rate was 79 +/- 4% in the rotational atherectomy plus stenting group and 75 +/- 3% in the rotational atherectomy plus balloon angioplasty group (p = 0.44). In conclusion, rotational atherectomy followed by stenting or balloon angioplasty is associated with favorable long-term outcomes. Compared with rotational atherectomy plus balloon angioplasty, routine stenting after rotational atherectomy does not provide additional benefits in the clinical outcomes in complex coronary lesions.