Rotational atherectomy multicenter registry: acute results, complications and 6-month angiographic follow-up in 709 patients

Role of intraaortic balloon pump counterpulsation in high risk coronary rotational atherectomy

OBJECTIVES

This study sought to evaluate the role of intraaortic balloon pump counterpulsation in preventing hemodynamic instability and promoting a successful outcome during percutaneous transluminal coronary rotational atherectomy in high risk patients.

BACKGROUND

The application of rotational atherectomy has widened to include patients with complex lesions and left ventricular dysfunction. Although intraaortic balloon pumping has been successfully used to provide hemodynamic support during balloon angioplasty, its role in high risk rotational atherectomy has not yet been defined.

METHODS

In a retrospective review of 159 consecutive high risk patients who underwent rotational atherectomy, 28 had an intraaortic balloon pump placed electively before the procedure (Group 1) whereas 131 did not (Group 2).

RESULTS

Group 1 was older and more likely to have multivessel disease and left ventricular dysfunction. Augmented diastolic pressure was maintained > 90 mm Hg in all Group 1 patients, and significant procedure-related hypotension was encountered in nine Group 2 patients, requiring an emergency intraaortic balloon pump in five. Procedural success was achieved in all 28 patients in Group 1 and in 118 in Group 2 (p = 0.07). Slow flow occurred in 18% and 17% of Group 1 and 2 patients, respectively. Among patients with slow flow, non-Q wave myocardial infarction occurred only in Group 2 (0% vs. 27%). On multivariate analysis, elective intraaortic balloon pump placement was the only variable to correlate with a successful procedure uncomplicated by hypotension (p < 0.05). Hospital stay and vascular complications were similar in both groups.

CONCLUSIONS

Elective placement of an intraaortic balloon pump before coronary rotational atherectomy in selected high risk patients promotes both procedural hemodynamic stability and a successful outcome.

Influence of adjunctive balloon angioplasty on coronary blood flow after rotational atherectomy

Rotational atherectomy is being performed with increasing frequency in a distinct subset of patients whose lesion characteristics are unfavorable for conventional balloon angioplasty. Although satisfactory luminal enlargement can be accomplished with the use of rotational atherectomy alone in some patients, adjunctive balloon angioplasty is necessary in most patients, to obtain a minimal residual angiographic result. To demonstrate responses associated with rotational atherectomy results, serial coronary blood flow measurements were obtained in a patient undergoing rotational atherectomy for unstable angina. Adjunctive balloon angioplasty resulted in normalization of post-stenotic coronary flow reserve. Recanalization by rotablator alone may not normalize coronary flow despite a satisfactory angiographic result.

Mechanism of high-speed rotational atherectomy and adjunctive balloon angioplasty revisited by quantitative coronary angiography: edge detection versus videodensitometry

High-speed rotational coronary atherectomy (RA) is primarily used to treat complex lesions. Quantitative angiographic analysis of such complex lesions by edge detection is often unsuitable, whereas videodensitometry, measuring vessel dimensions independently of the target stenosis contours, may offer potential advantages. To gain insight into the operative mechanism of RA and to study the agreement between the two quantitative angiographic methods in measuring the minimal luminal cross-sectional area, the edge detection and videodensitometry techniques were applied to coronary angiograms of 21 lesions in 19 patients with symptoms who underwent successful RA and balloon angioplasty (BA). Obstruction diameter as determined by edge detection increased from 1.00 +/- 0.31 mm before intervention to 1.35 +/- 0.29 mm after RA (p < 0.001) and further increased to 1.74 +/- 0.33 mm after adjunctive BA (p > 0.001). The mean between-method difference (edge detection minus videodensitometry) was 0.34 mm2 before intervention, 0.13 mm2 after RA, and 0.09 mm2 after adjunctive BA (not significant). The standard deviation of the differences decreased from +/- 0.87 mm2 before intervention to +/- 0.80 mm2 after RA (not significant) and increased after BA significantly to +/- 1.21 mm2 (p < 0.05). Thus edge detection and videodensitometry provided equivalent immediate angiographic results after RA and adjunctive BA. The good agreement after RA may reflect the operative mechanism of RA, which by ablation of noncompliant plaque material yields a circular symmetric lumen with smooth surface. The increased dispersion of the between-method differences observed after adjunctive BA presumably results from dissections, plaque ruptures, and loss of luminal smoothness after balloon dilatation.

Rotational atherectomy in restenotic lesions at the distal saphenous vein graft anastomosis

Restenotic lesions at distal saphenous vein graft (SVG) anastomoses have been notoriously difficult to treat with standard angioplasty techniques. We explored the potential of rotational atherectomy in three patients with nonthrombotic, focal restenoses at the SVG touch down. The Rotablator safely and successfully recanalized the lesions, allowing further treatment with dilation or stenting or both. Rotational atherectomy may warrant investigation as a treatment for nonthrombotic restenotic SVG lesions.

Emergency rotational ablation of a calcified left main coronary artery stenosis in a patient with ischemic induced cardiogenic shock

High-speed rotational ablation is ideal in the treatment of chronic calcified atherosclerotic lesions. This report describes an elderly woman with a prior history of coronary artery bypass surgery, who developed cardiogenic shock secondary to occlusion of a saphenous vein graft to the obtuse marginal branch of the circumflex coronary artery. Her left main coronary artery was heavily calcified and almost completely occluded. She was treated successfully by high-speed rotational ablation of her left main stenosis.