121 A District General Hospital Experience of Rotational Atherectomy in the United Kingdom

Abstract

AimsRotational atherectomy/rotablation (RA) has been traditionally considered a high risk procedure and performed in tertiary centres with on-site surgical backup. Our aim was to analyse RA with regards to procedural success and safety in the setting of a cardiac centre without on-site cardiac surgery.MethodsA retrospective analysis of all RA pts between Jan 2010 and April 2013 was undertaken. Demographic data and procedural details were collected from medical case notes, cathlab records, BCIS and radiographer’s database. Hospital, GP records and national mortality registry were used for follow-up information. F/u data was analysed at 30 days and 1 yr post procedure.Results184 pts underwent 206 PCI’s with RA in the study period of 40 months. This represents 5% of our total 3884 PCI work load. In comparison to non-RA group, RA group was older (74 vs. 67 yr) and had higher risk profile: HTN (72 vs. 68%), DM (35 vs. 21%). Procedures were elective in 153 (74%), ACS-41 (20%) and STEMI-12 (6%). 3-vessel CAD was present in 61 (30%), LMS disease in 26 pts (14%). Intervention was performed on LMS 20 (10%), LAD 111 (54%), LCx 30 (15%) and RCA 66 (32%), with 18 (9%) pts having multivessel RA. There were 9 (4%) ostial lesions, 35 (17%) bifurcation lesions, and 2 (1%) CTOs. There was previous failed PCI in 21 (10%) pts, with ad-hoc RA in 24 (12%) and the rest having upfront RA (161, 78%). Radial access was 38% and femoral in 62% with 6 and 7F catheters used equally. A single burr was used in 175 (85%). Burr sizes were: 1.25 mm (55%), 1.5 mm (39%). IVUS use in 45 (22%); prophylactic temporary PPM in 14 (10%) and prophylactic IABP in 9 (4%). Procedural success was achieved in 198 (96%) with 5 requiring balloon only dilation. Mean total radiation time was 43.8 min, with a mean DAP of 16793 cGy with >50% reduction after first 2 yrs and mean contrast load 270 ml with a 17% reduction after 2 yrs. No procedural comp were seen in 184 (89%) cases, major comp in 6% (12: vascular comp requiring surgery/transfusion-5; tamponade-3; temporary PPM related-2 and PCI wire related in 1; contrast nephropathy-2; coronary perforation due PCI wire-1; transfusion with no source of bleeding-1), and minor comp in 6% (13: hypotension requiring IABP-3; bradycardia requiring temporary PPM-1; coronary slow/no flow-2; coronary dissection-1; other coronary comp-2; other – hypotension, bradyarrhythmia, tachyarrhythmia treated medically-4). In hospital mortality was 1%(2: both ACS) and at 1 yr 5.8%(12) with 2% cardiac mortality. MACE rate (i.e. cardiac mortality, MI, TLR and CABG) at 1 month was 1.5% and at 1 yr 8.7% driven mainly by TLR due to ISR. Event free survival at 1 yr was 178 (86%).ConclusionsRA in the setting of off-site surgical backup is a safe and effective with an overall high procedural success rate. Ours is one of the largest series of RA pts in the DES era and support RA use in calcified coronary lesions. Event rate during 1 yr follow-up was mainly driven by TLR due to ISR.

Utility of the SYNTAX Score in the risk stratification of patients undergoing rotational atherectomy

“…Nevertheless, the number of RA procedures is increasing mainly due to the increasing need of PCI facilitation in the elderly population with severe calcifications in coronary arteries [ 5 , 9 ]. Since the RA procedure does not require cardiosurgical backup, more and more smaller centers have started performing RA [ 10 ]. This raises the need for an adequate pre-procedural risk stratification and patient selection in order to minimize the risk of complications in less experienced, low-volume centers.…”