Reappraisal Value of a Modified Rotational Atherectomy Technique in Contemporary Coronary Angioplasty Era

Abstract

Objectives. To introduce a modified rotational atherectomy (RA) procedure and investigate the early and midterm outcomes of the RA-facilitating diversified percutaneous coronary intervention (PCI) in a large group of aged patients with higher cardiovascular risk. Background. Previous studies about the outcomes of RA were limited with small sample size and low-risk population. Methods. Between January 2013 and November 2015, 1169 consecutive patients treated with modified RA-facilitated PCI were retrospectively enrolled, including de novo calcified lesions and in-stent restenosis. Patients were regularly followed up for at least 1 year. Major adverse cardiac events (MACE) were analyzed for all participants by different strategies. Cox regression analysis was performed to identify risk factors for the events. Results. The median age of patients was 75 years, with 11.7% of patients on maintenance hemodialysis. Most lesions (99.9%) were complex (American Heart Association type B2/C), and 68.3% were treated with RA + drug-eluting-stent (DES). Successful angiography was achieved in 97.8% cases, with 1.7% (20/1169) experiencing coronary perforation (including guidewire perforation). The incidence of MACE was 20.5% and 26.8% at 1-year and 2-year follow-up and were mainly driven by target lesion revascularization (TLR) (10.3% and 12.5%, respectively). The strategy of RA + DES had the lowest 2-year MACE, compared with the RA + drug-coated balloon and RA + plain old balloon angioplasty (14.5%, 30.5%, and 26.0%, respectively). Conclusions. The modified RA technique is a safe and effective tool in the contemporary PCI era, even in high-risk patients. The TLR rate was relatively high but acceptable in such complex lesions.

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

“…Emergence of drug-eluting stent (DES) has dramatically changed the indications of PCI, which included diffuse long calcified lesions. The lesion modification, which facilitate the delivery and expansion of DES, would be the most frequent purpose in the contemporary RA, and the long-term outcomes of DES following RA was acceptable [ 13 – 17 ], except specific lesions such as calcified nodule [ 18 ]. Moreover, RA might prevent the polymer damage, when DES was delivered to the calcified lesions [ 19 ].…”

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.…”

“…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][4][5][6] . Therefore, intravascular imaging devices have been frequently used in current PCI with RA [7][8][9] . Moreover, the intravascular imaging may be helpful in the selection of initial burr sizes or RotaWires (BOSTON SCIENTIFIC, Marlborough, MA, USA), especially for operators with insufficient experiences in RA 10 .…”

Contemporary treatment options for surmounting the conundrum of calcified coronaries

“…Once the burr has completely crossed the lesion, it can be advanced for longer times and over longer distances for final lesion "polishing". Luo et al 33 applied the modified strategy comprising: "double flush" with a cocktail from guiding catheter and RA system (increasing the flushing pressure for debris passing through the coronary microvasculature, cools down the Rotablator® turbine, and further reduces slow/no flow occurrence); the "imaging device passage" (1.5mm burr for IVUS crossable, and 1.75mm burr for IVUS uncrossable lesions, based on burr size); and "high" speed (160,000 to 220,000rpm) to cross, followed by "low" speed (140,000-160,000rpm) warrant efficient lesion cross the lesion and sufficient plaque modification.…”