North American Expert Review of Rotational Atherectomy

Abstract

Rotational atherectomy (RA) is an established tool in interventional cardiology for treatment of calcified coronary lesions. Over 3 decades of clinical experience and research, techniques have matured and outcomes have improved. Heterogeneity exists, however, in RA utilization and technique. We assembled a group of experienced RA operators and device experts to summarize and critique key elements of contemporary RA technique, to identify areas of consensus and controversy, and to offer recommendations for optimal performance for the practicing interventional cardiologist. Evolution in RA strategy toward a focus on lesion modification to facilitate balloon angioplasty and stenting has underpinned major advances in procedural safety, including opportunity to use smaller caliber equipment and radial access. Optimal technique and improved safety have permitted exploratory use of RA for different lesion types and reevaluation of procedural requirements, including flush solution composition and transvenous pacing. Preparedness to manage complications remains paramount and recommendations for operators and institutions are outlined.

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.…”

“…However, since those parameters (length, angle, diameter, or ratio) are continuous variables, it would be difficult for junior RA operators to anticipate the risk of complications without established cut-off values. For example, the recommended burr-to-artery ratio varies widely between European Consensus document (0.6) and North American Expert Review (0.4-0.6) 1,18 . Since the IVUS-crossability is a simple categorical variable (yes/no), it would be easy for junior RA operators to understand the risk of complications.…”

“…Rotational atherectomy (RA) is still a cornerstone for the treatment of coronary lesions with a high calcium content 1 . However, the incidence of severe complications is greater in percutaneous coronary interventions (PCI) with than without RA 2 , demanding further refinement in RA.…”

Impact of Lesion Preparation Technique on Side Branch Compromise in Calcified Coronary Bifurcations: A Subgroup Analysis of the PREPARE-CALC Trial

“…The differences in the mechanism of lesion preparation could therefore explain the superiority of RA over SCB in preventing side branch compromise observed in our study. Rotational atherectomy ablates hard plaque components while displacing and sparing soft tissues by the so-called differential cutting principle [ 26 ]. Although in current practice the role of RA has changed from aggressive debulking to plaque modification [ 27 ], the atheroablative effect of RA by reducing the volume of the plaque might still reduce the risk of carina shift during lesion preparation and after stent implantation.…”

Automated Quantitative Assessment of Coronary Calcification Using Intravascular Ultrasound

“…Because of its rigidity, circumferential calcification may prevent full dilation of the stent, which may lead to stent underexpansion, associated with increased risk of target vessel failure (Witzenbichler et al 2014). Specialized techniques, such as cutting balloons, rotational atherectomy or intracoronary lithotripsy (Sharma et al 2019), can be used to prepare calcified plaques to enable complete stent expansion. The beneficial effects of these plaque modification techniques depend directly on the extent and severity of calcification, so detailed knowledge is needed to guide the choice of lesion preparation method (Wijns et al 2015).…”