This study retrospectively analyzed the data within the U.S. Multicenter Registry for Rotational Ablation to determine the incidence of coronary perforation during rotational ablation, its angiographic predictors and clinical outcomes during 2953 consecutive patients, 3717 lesions. Patients were categorized into Group A (without perforation, N = 2931) and Group B (with perforation, N = 22 patients). Perforation occurred in 0.7% of procedures, and in 0.6% of lesions treated and was more frequent within the right (12/ 1105, 1.1%) and circumflex (9/761, 1.2%) arteries than the left anterior descending artery [1/1727, 0.06%; (P < 0.001)]. Morphologic features associated with increased perforation rates were eccentricity, tortuousity, and lesion length > 10 mm. Group B was assessed with regard to major complications, including death, surgery, myocardial infarction, or tamponade (type I); and minor complications; sealing with balloon angioplasty and without clinical sequelae (type II). There were 15 type I: emergency surgery in nine, of whom two died, and six infarctions (5 non-Q wave and one Q wave); and 7 type II patients. Coronary perforation, although a rare complication of rotational ablation, is seen more frequently in the right and circumflex coronary arteries than the left anterior descending artery, and occurs more frequently with lesion eccentricity, tortuousity, and length > 10 mm.