Incidence, predictors, and consequences of coronary dissection following high-speed rotational atherectomy

Rotational Atherectomy in Acute STEMI with Heavily Calcified Culprit Lesion is a Rule Breaking Solution

BACKGROUND

Calcified coronary lesions represent technical challenges during percutaneous coronary intervention and are associated with a high frequency of restenosis and target lesion revascularization. Rotational atherectomy has been shown to increase procedural success in severely calcified lesions, facilitate stent delivery in undilatable lesions and ensure complete stent expansion. However, rotational atherectomy in ST-elevation Myocardial Infarction (STEMI) is traditionally avoided given the concern for slow or no reflow and considered a contraindication in lesions with a visible thrombus by its manufacturer (Rotablator, Boston Scientific).

CONCLUSION

This case demonstrates the successful use of rotational atherectomy to facilitate dilation and revascularization of a heavily calcified culprit lesions in a patient with acute anterior STEMI with ongoing chest pain.

Rotational atherectomy: a "survivor" in the drug-eluting stent era

Mechanical debulking of coronary plaques with rotational atherectomy (RA) has been used for more than 20 years during percutaneous coronary interventions (PCI). Modification of plaque characteristics may be accomplished with selective ablation of inelastic fibrocalcific tissue. The use of RA, though reduced with the development of bare-metal stents (BMS) and even more with drug-eluting stents (DES), has never been completely abandoned. The present review will analyze reasons for conflicting results obtained in large series and randomized trials on this topic in the past, and will identify criteria for an appropriate use in current times.

Outcomes of small coronary artery stenting with bare-metal stents versus drug-eluting stents: results from the NHLBI Dynamic Registry

OBJECTIVES

Examine 1-year outcomes of patients with small coronary arteries in the National Heart, Lung, and Blood Institute Dynamic Registry (NHLBI) undergoing drug-eluting stent (DES) vs. bare-metal stent (BMS) placement.

BACKGROUND

While randomized trials of DES vs. BMS demonstrate reduced target vessel revascularization, it is unclear whether similar outcomes are seen in unselected patients after percutaneous coronary intervention (PCI) for small coronary arteries.

METHODS

Utilizing patients from the NHLBI Registry Waves 1-3 for BMS (1997-2002) and Waves 4-5 for DES (2004 and 2006), demographic, angiographic, in-hospital, and 1-year outcome data of patients with small coronary arteries treated with BMS (n = 686) vs. DES (n = 669) were evaluated. Small coronary artery was defined as 2.50-3.00 mm in diameter.

RESULTS

Compared to BMS-treated patients, the mean lesion length of treated lesions was longer in the DES treated group (16.7 vs. 13.1 mm, P < 0.001) and the mean reference vessel size of attempted lesions was smaller (2.6 vs. 2.7 mm, P < 0.001). Adjusted analyses of 1-year outcomes revealed that DES patients were at lower risk to undergo coronary artery bypass graft surgery (Hazard Ratio [HR] 0.40, 95% confidence interval [CI] 0.17-0.95, P = 0.04), repeat PCI (HR 0.53, 95% CI 0.35-0.82, P = 0.004), and experience the combined major adverse cardiovascular event rate (HR 0.59, 95% CI 0.42-0.83, P = 0.002). There was no difference in the risk of death and myocardial infarction (MI) (HR 0.78, 95% CI 0.46-1.35, P = 0.38).

CONCLUSIONS

In this real-world registry, patients with small coronary arteries treated with DES had significantly lower rates of repeat revascularization and major adverse cardiovascular events at 1 year compared to patients treated with BMS, with no increase in the risk of death and MI. These data confirm the efficacy and safety of DES over BMS in the treatment of small coronary arteries in routine clinical practice.

Disassembly of a rotablator: getting out of a trap

The rotablator burr rarely becomes trapped within calcified lesions. Manual traction can be ineffective and dangerous. We report a case that illustrates a novel technique involving use of a percutaneous snare in conjunction with partial disassembly of the rotablator device to remove a trapped burr without need for open surgical intervention.

Coronary sinus compression as a sign of cardiac tamponade

Coronary perforation and resultant cardiac tamponade are well-known but rare complications of percutaneous coronary interventions. We present a case that demonstrates coronary sinus compression caused by increasing pericardial pressure as a new sign of impending cardiac tamponade. This previously unreported angiographic sign preceded hemodynamic, symptomatic, and echocardiographic evidence of tamponade.

Trapped Rotablator: kokesi phenomenon

We experienced a rare complication of rotational atherectomy. The burr was trapped at the angled, calcified narrowing in the left anterior descending coronary artery. The burr was retrieved after the resection of the pulmonary artery and the left coronary artery. We will discuss the cause and prevention of this complication. Cathet. Cardiovasc. Intervent. 49:82-84, 2000.

[Rotational atherectomy: technique, indications, results]

Rotational atherectomy (Rotablation) represents one of the alternative devices to treat complex coronary artery stenoses. Rather than increasing luminal diameter by arterial stretching and plaque fracture as with balloon angioplasty, rotablation debulks atherosclerotic plaque with an abrasive diamond coated burr. The basic physical principle is differential cutting. It allows the advancing burr to selectively cut inelastic material while elastic tissue deflects away from the burr. 95% of the particles generated by the Rotablator are less than 5 microns. They are removed by the body's reticuloendothelial system. There are different strategies to perform a rotablation, regarding the number of burrs used and the final burr-to-artery ratio. An adjunctive PTCA is recommended without proof by randomized studies so far. The best indication for the Rotablator is the undilatable lesion. Lesion modification (debulking) as a method of improving vessel compliance seems to be also usefull in diffusely diseased and calcified vessels, as well as in aorto-ostial and angulated stenoses. The instent restenoses is a new indication. Randomized studies will have to proof if there is an advantage for rotablation compared to PTCA. Restenosis rates appear comparable to balloon angioplasty.