Orbital atherectomy for the treatment of severely calcified coronary lesions: evidence, technique, and best practices

Abstract

The presence of severe coronary artery calcification is associated with higher rates of angiographic complications during percutaneous coronary intervention (PCI), as well as higher major adverse cardiac events compared with non-calcified lesions. Incorporating orbital atherectomy (OAS) for effective preparation of severely calcified lesions can help maximize the benefits of PCI by attaining maximal luminal gain (or stent expansion) and improve long-term outcomes (by reducing need for revascularization). Areas covered: In this manuscript, the prevalence, risk factors, and impact of coronary artery calcification on PCI are reviewed. Based on current data and experience, the authors review orbital atherectomy technique and best practices to optimize lesion preparation. Expert Commentary: The coronary OAS is the only device approved for use in the U.S. as a treatment for de novo, severely calcified coronary lesions to facilitate stent delivery. Advantages of the device include its ease of use and a mechanism of action that treats bi-directionally, allowing for continuous blood flow during treatment, minimizing heat damage, slow flow, and subsequent need for revascularization. The OAS technique tips reviewed in this article will help inform interventional cardiologists treating patients with severely calcified lesions.

Plaque modification of severely calcified coronary lesions via orbital atherectomy: Single‐center observations from a complex Veterans Affairs cohort

“…The optimal results presented here are likely due to the unique mechanism of action of OA and Chocolate balloon angioplasty. As previously reviewed, OA has an orbital and differential sanding mechanism that reduces plaque burden, creating vessel compliance while minimizing damage to the medial layer of the vessel . The Chocolate balloon consists of a mounted nitinol constraining structure specifically designed for uniform, controlled inflation and rapid deflation, resulting in atraumatic dilatation without the need for cutting or scoring.…”

“…The Diamondback 360 coronary OA system (Cardiovascular Systems, Inc. [CSI], St Paul, MN) was utilized in all cases analyzed. As previously reviewed, the mechanism of this device has been shown to be useful in the treatment of severely calcified, noncompliant coronary lesions prior to appropriate percutaneous transluminal coronary angioplasty and adequate stent deployment …”

“…Thus, pretreatment interventions focus on decreasing the degree of calcifications to facilitate adequate angioplasty. The Diamondback 360 coronary orbital atherectomy (OA) system (Cardiovascular Systems, Inc. [CSI], St Paul, MN) is a proven asset as an alternative to rotational atherectomy (RA) for the treatment of these heavily calcified coronary lesions . The purpose of this study was to retrospectively analyze the safety and effectiveness of OA for the treatment of high‐risk VA patients with severely calcified coronary lesions.…”

Predictors of side branch compromise in calcified bifurcation lesions treated with orbital atherectomy

“…Orbital atherectomy (OA) is a newly FDA approved device for treatment of severely calcified coronary lesions which works on the principle of elliptical burr movement. ORBIT II clinical trial evaluated the safety of OA in de novo calcified coronary lesions and demonstrated that complication rate was comparable to historical controls of rotational atherectomy (RA); however, bifurcation lesions were excluded from the trial …”

“…ORBIT II clinical trial evaluated the safety of OA in de novo calcified coronary lesions and demonstrated that complication rate was comparable to historical controls of rotational atherectomy (RA) 11 ; however, bifurcation lesions were excluded from the trial. 12 The aim of the study was to identify the predictors of SB compromise in calcified bifurcation PCI with OA using 3-dimensional (3D) quantitative coronary angiography (QCA) and OCT imaging data.…”