Intravascular ultrasound-factors associated with slow flow following rotational atherectomy in heavily calcified coronary artery

Abstract

Intravascular ultrasound (IVUS) can provide useful information in patients undergoing complex percutaneous coronary intervention with rotational atherectomy (RA). The association between IVUS findings and slow flow following rotational atherectomy (RA) has not been investigated, although slow flow has been shown to be an unfavorable sign with worse outcomes. The aim of this study was to determine the IVUS-factors associated with slow flow just after RA. We retrospectively enrolled 290 lesions (5316 IVUS-frames) with RA, which were divided into the slow flow group (n = 43 with 1029 IVUS-frames) and the non-slow flow group (n = 247 with 4287 IVUS-frames) based on the presence of slow flow. Multivariate regression analysis assessed the IVUS-factors associated with slow flow. Slow flow was significantly associated with long lesion length, the maximum number of reverberations [odds ratio (OR) 1.49; 95% confidence interval (CI) 1.07–2.07, p = 0.02] and nearly circumferential calcification at minimal lumen area (MLA) (≥ 300°) (OR, 2.21; 95% CI 1.13–4.32; p = 0.02). According to the maximum number of reverberations, the incidence of slow flow was 2.2% (n = 0), 11.9% (n = 1), 19.5% (n = 2), 22.5% (n = 3), and 44.4% (n = 4). In conclusion, IVUS findings such as longer lesion length, the maximum number of reverberations, and the greater arc of calcification at MLA may predict slow flow after RA. The operators need to pay more attention to the presence of reverberations to enhance the procedure safety.

Secondary rotational atherectomy is associated with reduced occurrence of prolonged ST-segment elevation following ablation

“…When performing PCI with RA for calcified lesions, the slow-flow phenomenon is frequently encountered [ 12 ]. Previous studies have reported that lesion length as measured angiographically was associated with the occurrence of slow flow after RA [ 7 , 17 ] and that the arc of calcification at the minimal lumen area derived from IVUS represents a new factor associated with slow flow after RA [ 18 ]. Furthermore, Sakakura et al showed that IVUS cross-ability was also significantly associated with slow flow after RA [ 19 ].…”

Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics: update 2023

“…Because reverberations are closely associated with smooth surface of the calcified lesions [41], reverberations may be observed in the calcified lesions after RA as well as the unmodified calcified lesions with smooth surface. Recently, Jinnouchi, et al reported the association between slow flow following RA and reverberations [42]. However, the clinical significance of the natural reverberations has not sufficiently investigated.…”

“…Lesion length and burr-to-artery ratio were reported as the determinants of slow flow [66,93]. Furthermore, IVUS findings such as longer lesion length, the maximum number of reverberations, and the greater arc of calcification at MLA may predict slow flow after RA [42].…”

The role of invasive and non-invasive imaging technologies and calcium modification therapies in the evaluation and management of coronary artery calcifications

“…Notably, IVUS may also assist in predicting, and thus avoiding, procedural complications such as the no- or slow-reflow phenomenon. Lesions associated with CAC extending >24 mm, an increase in the number of reverberations post-modification, and an arc of calcium at the minimum lumen area >300° were associated with increased rates of slow/no reflow and may alert physicians as to which patients may be at higher risk and might require preventative measures ( 16 ).…”