Rotational atherectomy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
Rotablation is used as a debulking device. It is generally not used as a stand alone device, and is generally used to facilitate greater lumen expansion via improving vessel compliance prior to stent placement. The procedure can be done in coronary arteries and in peripheral arteries.
Indications
- The target lesion is in a native vessel, not a saphenous vein graft
- The target lesion is deemed to be undilatable by a balloon due to calcium or fibrosis.
- The target lesion is an ostial lesion
- The target lesion is located at a bifurcation and debulking is required to reduced the risk of plaque shift
- The target lesion could not be crossed with the primary device
Contraindications
- Ejection fraction < 30%
- Shock or hypotension
- The target lesion is the sole remaining conduit
- The presence of dissection
- Severe angulation at the target lesion
Strategies to reduce no reflow during the procedure
- Liberal administration of calcium channel blockers such as diltiazem (200 micrograms administered via the intracoronary route)
- Multiple short runs of rotablation
- A slower initial speed of rotablation such as 140,000 to 160,000 rotations per minute (RPM)
- Minimal deceleration during the bur runs
- Allowing a period of recovery between bur runs
- Avoid over-sizing the bur to minimize downstream embolization
- Use of a "Rotablator flush":
- 0.9% NS 1000 cc
- 10,000 Units of unfractionated heparin (10 units / ml)
- Verapamil 10 mg (10 micrograms / ml)
- Nitroglycerin 5 mg (5 microgams / ml)
Efficacy
The comparative efficacy of rotational atherectomy has been compared in the following studies / trials:
The ERBAC Trial
The SPORT Trial
This trial Randomized 735 patients to bare metal stenting with or without prior rotational atherectomy. THere were better acute results among patients pre treated with rotational atherectomy. There was no difference in TLR rates in follow-up [2]