The Safety and Efficacy of Resolving Burr Entrapment by the Ping-Pong and Mother-in-Child Techniques.

Burr entrapment is a serious risk when performing rotational atherectomy on specific anatomical features of lesions such as tortuosity, calcification, and acute angulation. This occurrence, known as the Kokeshi phenomenon in Japanese, is caused by the burr's proximal section being unable to ablate while pulling back the burr, leaving the distal end of the burr covered in diamond crumbs capable of lesion ablation following rotation. There are reports of different approaches used to retrieve an entrapped rotablator burr. In this case, we demonstrate that the ping-pong and mother-in-child techniques, which use separate guide catheters to engage the same coronary artery wiring across the lesion afterward and deep engagement of guide extension catheter manual traction, are highly effective and secure methods for retrieval.

Efficacy and Safety of an Upfront RotaTripsy Strategy in the Treatment of De Novo and In-Stent Restenosis Cases.

BACKGROUND: Use of both rotational atherectomy (RA) and intravascular lithotripsy (IVL)-the "RotaTripsy" technique-offers a potentially synergistic calcium-modification strategy that can treat both luminal and abluminal calcification. An upfront RotaTripsy strategy using an undersized burr in large-caliber coronaries also offers the advantage of facilitating IVL catheter passage while being able to undertake the procedure with a 6-Fr system. METHODS: Consecutive patients with heavily calcified lesions on angiographic or intravascular imaging and large target-vessel caliber (≥3 mm) who underwent an upfront RA followed by IVL between July 2021 and January 2022 were included in this study. Study aims were to evaluate periprocedural efficacy and safety. RESULTS: Of the 21 patients included, RotaTripsy was used for treatment of de novo lesions in 12 patients (57%) and for in-stent-restenosis in 9 patients (43%). Seven cases of in-stent restenosis (ISR) involved 2 layers of stents. Mean reference vessel diameter was 3.67 ± 0.46 mm and baseline diameter stenosis was 77.4 ± 11.3%. Average RA burr-to-artery ratio was 0.43 ± 0.05 and IVL balloon-to-artery ratio was 0.93 ± 0.06, with IVL balloon crossing the lesion in all cases following RA. Procedural success was attained in 20 of 21 cases; 1 periprocedural complication (a death related to coronary perforation following stent postdilation) was recorded. CONCLUSIONS: An upfront RotaTripsy strategy is associated with a high degree of procedural success in de novo lesions and ISR cases by facilitating the use of a smaller burr-to-artery ratio and smaller-bore vascular access. Larger studies are required to further evaluate the potential benefits of an upfront RotaTripsy strategy from a safety and cost-benefit perspective.

Transvascular Balloon Occlusion: A Novel Bailout Strategy in Large Left Main Perforations.

Several complications have been reported in rotational atherectomy, and these complications are closely associated with cardiac tamponade, emergent surgery, and death. Here we describe a case of left main coronary artery, bullet-like perforation treated with a novel approach-transvascular balloon occlusion. (Level of Difficulty: Advanced.).

Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy.

BACKGROUND: Percutaneous coronary interventions (PCI) in calcified coronary artery lesions are associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using calcium modifying techniques such as Rotational Atherectomy (RA) or Intravascular Lithotripsy (IVL) has been advocated. Studies comparing these technologies are lacking. We aimed to compare in-stent pressure gradients, evaluated by vessel fractional flow reserve (vFFR), in calcific lesions treated using either RA or IVL. METHODS: Patients undergoing either RA- or IVL-assisted PCI from two European centers were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post-PCI in-stent pressure gradients calculated by vFFR (vFFRgrad). Secondary outcomes included the proportion of patients with complete functional revascularization defined as distal vFFR post-PCI (vFFRpost) ≥ 0.90. RESULTS: From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0.65 ± 0.13 RA and 0.67 ± 0.11 IVL). After PCI, in-stent pressure gradients were significantly lower in the IVL group (0.032 ± 0.026 vs 0.043 ± 0.026 in the RA group, p = 0.024). The proportions of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; p = 0.669). CONCLUSIONS: Calcific lesions preparation with IVL is effective and resulted in lower in-stent pressure gradients compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL.

Transradial versus trans-femoral access site in high-speed rotational atherectomy in Sweden.

BACKGROUND: Radial artery is the preferred access site in contemporary percutaneous coronary intervention (PCI). However, limited data exist regarding utilization pattern, safety, and long-term efficacy of transradial artery access (TRA) PCI in heavily calcified lesions using high-speed rotational atherectomy (HSRA). METHODS: All patients who underwent HSRA-PCI in Sweden between 2005 and 2016 were included. Outcomes were major adverse cardiac events (MACE, including death, myocardial infarction (MI) or target vessel revascularisation (TVR)), in-hospital bleeding and restenosis. Inverse probability of treatment weighting was used to adjust for the non-randomized access site selection. RESULTS: We included 1479 patients of whom 649 had TRA and 782 transfemoral artery access (TFA) HSRA-PCI. The rate of TRA increased significantly by 18% per year but remained lower in HSRA-PCI (60%) than in the overall PCI population (85%) in 2016. TRA was associated with comparable angiographic success but significantly lower risk for major (adjusted OR 0.16; 95% CI 0.05-0.47) or any in-hospital bleeding (adjusted OR 0.32; 95% CI 0.13-0.78). At one year, the adjusted risk for MACE (HR 0.87; 95% CI 0.67-1.13) and its individual components did not differ between TRA and TFA patients. The risk for restenosis did not significantly differ between TRA and TFA HSRA-PCI treated lesions (adjusted HR 0.92; 95% CI 0.46-1.81). CONCLUSION: HSRA-PCI by TRA was associated with significantly lower risk for in-hospital bleeding and equivalent long-term efficacy when compared with TFA. Our data support the feasibility and superior safety profile of TRA in HSRA-PCI.

[Focus on high speed rotational atherectomy by Rotablator in 2021 and datas from France PCI registry]. / Mise au point sur l'athérectomie rotationnelle à haute vitesse par Rotablator en 2021 et données du registre France PCI.

Developed in the late 1980s, rotational atherectomy has raised a lot of hope for its innovative principle of selective ablation, allowing volume reduction (instead of redistribution) of atherosclerotic plaque, while sparing healthy tissue. Long shunned for its disappointing results on restenosis, the Rotablator finally reasserted itself in the 2000s; era of drug eluting stents and coronary angioplasty boom, thus generating emergence of complex lesions. Indeed, the Rotablator has demonstrated an undeniable benefit in complex (type C) and calcified lesions preparation (before stenting), with a procedural success rate of 95%. Although these lesions only represent a small amount (2-3%) of percutaneous coronary interventions (PCI), they remain a technical impasse for plain-old balloon angioplasty strategy, making the Rotablator more suitable for these resistant lesions' treatment. Registry data attest the safety of this therapy, with a rate of peri-procedural complications and in-hospital mortality comparable to conventional angioplasty (France PCI register). However, certain specific, rare but serious complications (burr entrapment, broken Rotawire, coronary perforation) justify trained teams, perfect knowledge of the equipment, and strict compliance with good practice guidelines. In 2018, the rise of a new method of atherectomy by intra-vascular lithotripsy (Shockwave) has coincided with Rotablator decreasing activity (this finding being biased by a general decrease in PCI activity due to Covid pandemic). This therapeutic range's enhancement revolutionizes calcified lesions treatment, tending towards precise targeting of each indication, depending in particular on calcium distribution's anatomy in the plaque.

Intravascular Imaging Guidance Reduce 1-Year MACE in Patients Undergoing Rotablator Atherectomy-Assisted Drug-Eluting Stent Implantation.

Objectives: This study aimed to investigate the incidence of 1-year major adverse cardiac events (MACE) compared between intravascular imaging guidance and angiographic guidance in patients undergoing rotablator atherectomy (RA)-assisted percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Methods: This retrospective analysis included 265 consecutive patients with heavy calcified lesion who underwent RA-assisted PCI with DES implantation at our institution during the January 2016-December 2018 study period. This study was approved by the Siriraj Institutional Review Board. Patients were divided into either the angiographic guidance PCI group or the imaging guidance PCI group, which was defined as intravascular ultrasound or optical coherence tomography. The primary endpoint was 1-year MACE. Results: Two hundred and sixty-five patients were enrolled, including 188 patients in the intravascular imaging guidance group, and 77 patients in the angiographic guidance group. One-year MACE was significantly lower in the imaging guidance group compared to the angiographic guidance group (4.3 vs. 28.9%, respectively; odds ratio (OR): 9.06, 95% CI: 3.82-21.52; p < 0.001). The 1-year rates of all-cause death (OR: 8.19, 95% CI: 2.15-31.18; p = 0.002), myocardial infarction (MI) (OR: 6.13, 95% CI: 2.05-18.3; p = 0.001), and target vessel revascularization (TVR) (OR: 3.67, 95% CI: 1.13-11.96; p = 0.031) were also significantly lower in the imaging guidance group compared with the angiographic guidance group. The rate of stroke was non-significantly different between groups. Conclusion: In patients with heavy calcified lesion undergoing RA-assisted DES implantation, the intravascular imaging guidance significantly reduced the incidence of 1-year MACE, all-cause death, MI, and TVR compared to the angiographic guidance.

Comparison of drug-eluting stents vs. drug-coated balloon after rotational atherectomy for severely calcified lesions of nonsmall vessels.

Calcified lesion is a risk factor for adverse events, even in the drug-eluting stent (DES) era. Recently, drug-coated balloon (DCB) has been shown to have favourable results for in-stent restenosis and small vessels, but its results for calcified lesions are unknown. This study aimed to clarify the rotational atherectomy (RA) and DCB results for calcified lesions of nonsmall vessels. A total of 194 consecutive de novo lesions from 165 cases underwent RA for calcified lesions of nonsmall vessels between January 2016 and August 2018 in a single centre. Overall, 8 cases/10 lesions were excluded because of RA followed plain old balloon angioplasty (POBA). Remaining lesions were grouped into the DES (88 cases/104 lesions) and DCB (69 cases/80 lesions) groups and then compared retrospectively. The primary endpoint was post-discharge major adverse cardiovascular events (MACE) at 1 year, and it was defined as cardiac death, noncardiac death, target-vessel-related myocardial infarction, target lesion revascularization (TLR), and major bleeding (BARC ≥ type 3). There was no difference in the clinical follow-up rate between RA + DES (96/104 lesions) and RA + DCB (78/80 lesions). The post-discharge MACE values after 1 year of RA + DES and RA + DCB were 8% and 11% (P = 0.30), respectively, in terms of cardiac death (0% vs. 0%, respectively), noncardiac death (4% vs. 3%, respectively, P = 0.36), target-vessel-related myocardial infarction (0% vs. 0%, respectively), TLR (4% vs. 8%, respectively, P = 0.30), and major bleeding (1% vs. 0%, respectively). For calcified lesions of nonsmall vessels, RA + DCB showed good results as well as RA + DES. RA + DCB is a potential new strategy for these lesions.

Current Treatment Modalities for Calcified Coronary Artery Disease: A Review Article Comparing Novel Intravascular Lithotripsy and Traditional Rotational Atherectomy.

The coronary artery calcium score is considered the most useful marker for predicting coronary events. The high score reflects heavy calcification in the vessel, which is more challenging to treat with the percutaneous intervention (PCI). To prepare this type of heavily calcified lesion intravascular lithotripsy (IVL) technology can be used prior to PCI, which is based on the concept of converting electrical energy into mechanical energy. It harmlessly and selectively disrupts both the shallow and deep deposits of calcium. The balloon-based catheters of this system emit sonic waves that transfer to the adjacent tissue resulting in improvement in vessel compliance with the slightest soft tissue loss. Therefore, making the treatment of calcified lesions more feasible, effective, and also simplify complex lesions. The lesions considered for lithotripsy-enhanced balloon dilation include calcified coronary lesions and peripheral vasculature lesions. This article reviews the use of IVL in calcified coronary artery disease, its advantages, and disadvantages while comparing it with other techniques like high-pressure balloons and rotational atherectomy devices. A thorough search of databases like PubMed and Google Scholar was performed, which uncovered 35 peer review articles. Keywords utilized in the data search were calcified coronary artery disease, coronary lithotripsy, calcification, and calcified atherosclerotic plaque. According to rotational atherectomy and intravascular lithotripsy trials, the latter was safer, mainly by decreasing atheromatous embolization risk. Deciphering these studies, it seems like IVL is better at parameters like procedural and clinical success rate, acute lumen gain, and less residual stenosis except in-hospital major adverse cardiovascular events (MACE), which was better in rotational atherectomy (RA). However, when lesion crossings are present, the atherectomy technique is still considered as first-line therapy. In clinical practice, despite these encouraging data for treating calcified lesions, IVL is grossly underutilized because of substantial costs and perceived significant procedural risk effects on the cardiac rhythm like causing 'shock topics' and asynchronous cardiac pacing. More longer-term clinical data and extensive researches are required to validate its safety and efficiency.

Effects of high-speed rotational atherectomy in peripheral artery disease patients with calcified lesions: a retrospective multicenter registry.

Calcified lesions still remain a technical challenge even in the treatment of infrainguinal artery disease. The aim of this retrospective, multicenter observational study was to investigate interventional outcomes of a high-speed rotational atherectomy device (Rotablator™) and to compare clinical outcomes in patients who underwent Rotablator and those who did not even after failed balloon angioplasty because of underlying calcified lesions. This study enrolled patients who underwent Rotablator (Rota group) and those who did not (Non-rota group) between January 2010 and 2014 December at 12 hospitals. A total of 67 limbs and 68 lesions in 65 patients were included (Rota group; 54 limbs and 55 lesions in 52 patients, Non-rota group; 13 limbs and 13 lesions in 13 patients). In the Rota group, a technical success rate was 94.5% with a complication rate of 1.8%, and all lesions underwent subsequent postdilatation following the adjunctive use of Rotablator, and approximately half of above-the-knee lesions underwent stent implantation. The Rota group had a significantly lower clinically driven reintervention rate at 12 months than the Non-rota group (26.5% vs. 58.3%, respectively, p = 0.046). In addition, Rota group showed a trend toward a higher amputation-free survival compared to the Non-rota group at 1 month (Rota; 98.0% vs. Non-rota; 84.6%, respectively, p = 0.10). Rotablator was used as an adjunctive device with a high technical success and a low complication rates, and Patients who underwent Rotablator yielded a significantly lower clinically driven reintervention rate at 12 months compared to those who did not even after failed balloon angioplasty.