Incidence and Mechanisms of Coronary Perforations during Rotational Atherectomy in Modern Practice

Abstract

Objective. Heavy calcifications remain formidable challenges to PCI, even for well-experienced operators. However, rotational atherectomy (RA)-induced coronary perforations (CPs) still could not be obviated. This study was to explore incidence and mechanisms of RA-induced CP in real-world practice. Knowing why CPs occur in RA should help operators avert such mishaps. Method. Patients who received coronary RA from April 2010 to December 2019 with keywords related to perforations were retrieved from database. The procedure details, angiography, and clinical information were reviewed in detail. Results. A total of 479 RAs were performed with 11 perforations in 10 procedures among 9 patients documented. The incidence of RA-induced CP was 2.1%. The RA vessels were distributed in different territories, including first diagonal branch. Most CPs could be treated conservatively, but prolonged profound shock predisposed to poor outcome. CPs caused by rotawire tip occurred in 18.2% of cases, inappropriately sized burrs in 18.2% of cases, and rotawire damage with subsequent transection and perforation in another 18.2% of cases. A total of 5 (45.5%) perforations were caused by unintended and unnoticed bias cutting into noncalcified plaques (4, 36.4%) or through calcified vessel wall (1, 9.1%). The mechanisms for certain CPs were unique and illustrated in diagrams. Conclusion. CPs due to RA occur in certain percentage of patients. The mechanisms for CPs are diverse. Wire damage with subsequent transection could occur due to inappropriately repetitive burr stress on the wire body. A significant portion was due to unintended and unnoticed bias cutting into noncalcified plaque or through calcified vessel wall.

Comparison of the incidence of periprocedural myocardial infarction between percutaneous coronary intervention with versus without rotational atherectomy using propensity score-matching

“…The frequency of RA usage was greater in our catheter laboratory than Japanese national PCI registry 5 , which could be an institutional bias. Furthermore, the incident of coronary perforation or device entrapment was 0% in the RA group, which was low as compared to literatures 3 , 15 , 46 . We might be familiar with various techniques such as halfway RA to prevent severe complications 47 .…”

Stent-graft and double-guiding catheter technique to rescue iatrogenic coronary perforation

“…Despite the benefits in terms of proper stent implantation, rotational atherectomy and excessive balloon angioplasty increases the risk of coronary artery perforation. The perforation rate with the use of rotational atherectomy during PCI ranges from 2.1% [ 6 ] to 3.3% [ 7 ]. The alternative techniques include excimer laser coronary atherectomy (ELCA), intravascular lithotripsy and non-atherectomy devices, such as scoring and cutting balloons.…”

Rotablation in Patients with Advanced Renal Insufficiency through End-Stage Renal Disease: Short- and Intermediate-Term Results

“…After stent implantation, dual-antiplatelet therapy with aspirin (100 mg/day) and clopidogrel (75 mg/day; or ticagrelor 90 mg twice a day) were continued for at least 12 months in the case of DES or three months in the case of bare-metal stent (BMS) implantation. The above method was used and had been published in our previous works [ 12 , 20 , 21 ].…”