Current status of rotational atherectomy

Abstract

Despite the increasing use of percutaneous transluminal coronary angioplasty and intracoronary stent placement for the treatment of obstructive coronary artery disease, a large subset of coronary lesions cannot be adequately treated with balloon angioplasty and/or intracoronary stenting alone. Such lesions are often heavily calcified or fibrotic and undilatable with the present balloon technology and attempts to treat them with balloon angioplasty or intracoronary stent placement often lead to vessel dissection or incomplete stent deployment with resultant adverse outcomes. Rotational atherectomy remains a useful niche device for the percutaneous treatment of such complex lesions, usually as an adjunct to subsequent balloon angioplasty and/or intracoronary stent placement. In contrast to balloon angioplasty or stent placement that widen the coronary lumen by displacing atherosclerotic plaque, rotational atherectomy removes plaque by ablating the atherosclerotic material, which is dispersed into the distal coronary circulation. Other lesion subtypes amenable to treatment with this modality include ostial and branch-ostial lesions, chronic total occlusions, and in-stent restenosis. This review discusses the technique and principles of rotational atherectomy, the various treatment strategies for its use (including adjunctive pharmacotherapy), the lesion-specific applications for this device, and the complications unique to this modality. Recommendations are also made for its use in the current interventional era.

Evaluation of the Diamondback 360 Coronary Orbital Atherectomy System for treatingde novo, severely calcified lesions

“…Calcified lesions have been shown to respond poorly to balloon angioplasty and therefore are associated with a high frequency of restenosis, target lesion revascularization (TLR) [24], vessel dissection during PCI [21], failure to deliver a stent, balloon ruptures [25,26] and undilatable lesions [27,28]. Up to 50% of coronary stents deployed in calcified lesions were found to have asymmetric stent expansion [29], potentially increasing the likelihood of stent thrombosis and/or restenosis [30].…”

Heavily Calcified Coronary Lesions Preclude Strut Apposition Despite High Pressure Balloon Dilatation and Rotational Atherectomy In-Vivo Demonstration With Optical Coherence Tomography

“…4 However, in cases 2 and 3, the superficial calcification was not completely cleared, preventing optimal stent expansion and apposition. Both are desirable to optimize DES safety and efficacy.…”

“…1,2 If balloons cannot cross or be expanded and the poorly steerable, thin, uncoated Rotablator ® wire (Boston Scientific, Natick, MA, USA) can be advanced, rotational atherectomy can result in favorable lesion modification that facilitates lesion dilatation and stent expansion. 3,4 Other methods of lesion preparation (eg, cutting balloon, high pressure pre-and post-dilatation) have been advocated for obtaining optimal stent expansion and apposition. Based on the examination of 3 representative cases with optical coherence tomography (OCT), we explain why optimal strut apposition remains an elusive target in the presence of heavy eccentric calcified plaques.…”

Shaft Rupture of Ultra-High Pressure Balloons

“…Our cases highlight the fact that optimal preparation is of utmost importance in treating such lesions. Rotablation is the most frequently applied method to deal with this problem [4], but is not available in all centers. As an alternative, ultra-high pressure balloons have been developed to deliver pressures up to 35 atm to crack even the hardest circular calcifications found in the human coronary system.…”