Effect of cutting balloon after rotational atherectomy in severely calcified coronary artery lesions as assessed by optical coherence tomography

Abstract

Objectives Using optical coherence tomography (OCT), we evaluated the effect of a cutting balloon (CB) compared with a conventional balloon after rotational atherectomy (RA) and before stenting in severely calcified coronary lesions. Background A CB is designed to create discrete incisions to facilitate fracture of severely calcified plaque. Methods OCT was performed preintervention (if possible), post‐RA, and poststent implantation. RA modification of calcium was defined as a polished, concave, round‐shaped surface. Calcium fracture was defined as a break in the calcium plate. The effects of calcium modification and stent expansion between CB (n = 18) versus conventional balloon (n = 23) following RA were compared. Results Median patient age was 72 years with 24% on hemodialysis. The amount of calcium and the length of RA modification were comparable between the CB and conventional balloon groups. Final poststent OCT showed that the number and thickness of calcium fracture were greater after CB versus conventional balloon, resulting better stent expansion (78.9% [IQR: 72.4–88.1] vs. 66.7% [IQR: 55.0–76.7], p < 0.01). In the multivariable model, after adjusting for the amount of calcium, CB use was an independent predictor of the presence of calcium fracture (odds ratio 30.0; 95% confidence interval 2.7–994.1, p = 0.004) and an independent predictor for greater stent expansion (regression coefficient 7.4; 95% confidence interval 0.5–14.3, p = 0.04). Conclusion In severely calcified lesions calcium fracture was more often associated with RA followed by CB compared with RA followed by conventional balloon predilation before stenting. CB use was also a determinant of greater stent expansion.

Rotational Atherectomy: A Contemporary Appraisal

“…Cutting balloon use was an independent predictor of the presence of calcium fracture and greater stent expansion, suggesting that this might be a superior lesion preparation strategy following RA prior to stent implantation. [67] The presence of residual dogboning of angioplasty balloon at low-pressure inflation indicates inadequate plaque modification and merits consideration for a larger sized burr. Contemporary DES are the standard treatment of choice following RA.…”

Comparison of the incidence of slow flow after rotational atherectomy with IVUS-crossable versus IVUS-uncrossable calcified lesions

“…Second, our results may be useful for establishing an educational program for junior RA operators. Because many literatures regarding RA and imaging devices have been published 1,[3][4][5][6][7][8][9][10] , even junior RA operators may be able to select an appropriate burr size, RotaWire, and RA strategy as long as an imaging device can cross the lesion before RA. However, as we shown here, there were many lesions that an IVUS catheter cannot cross, and the incidence of slow flow was greater in IVUS-uncrossable lesions.…”

“…Recently, many groups rigorously published research articles regarding RA with intravascular imaging devices 3 , 4 , 6 – 9 . Moreover, several review articles explain the interpretation of intravascular imaging findings in RA to facilitate use of imaging devices in RA 1 , 5 , 10 .…”

“…However, the incidence of severe complications is greater in percutaneous coronary interventions (PCI) with than without RA 2 , demanding further refinement in RA. Intravascular imaging devices including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) can provide useful information regarding calcification such as depth, longitudinal length, and arch of calcification 3 – 6 . Therefore, intravascular imaging devices have been frequently used in current PCI with RA 7 – 9 .…”

Treating severely calcified coronary artery disease: A potpourri of choices!

“…In the current issue, Amemiya et al report the outcomes of their single center study comparison of the effects of calcium modification and stent expansion using OCT with CB versus conventional balloon angioplasty following RA in 41 patients with moderate to severely calcified coronary lesions. Patients with left main coronary artery lesions and chronic total occlusions were excluded.…”