A Novel Rotablator Technique (Low-Speed following High-Speed Rotational Atherectomy) Can Achieve Larger Lumen Gain: Evaluation Using Optimal Frequency Domain Imaging

Abstract

Background. While the evaluation of burr speed was discussed regarding platelet aggregation, the association between platform speed and acute lumen gain of rotational atherectomy remains unknown. Methods. Through the evaluation of the potential of low-speed rotational atherectomy (LSRA) in in-vitro experiments, minimum lumen diameter (MLD) and minimum lumen area (MLA) after conventional high-speed rotational atherectomy (HSRA group) and those after LSRA following HSRA (LSRA+HSRA group) treated by 1.5 mm burrs were measured by optical frequency domain imaging (OFDI) in 30 consecutive human lesions. Results. The in-vitro experiments demonstrated that MLD and MLA after LSRA+HSRA were significantly larger (MLD: LSRA+HSRA=1.50 ±0.05 mm, HSRA= 1.43 ±0.05 mm, p=0.015; MLA: LSRA+HSRA= 1.90 ±0.17 mm2, HSRA= 1.71±0.11 mm2, and p= 0.037), requiring more crossing attempts (LSRA= 134 ±20 times, HSRA= 72 ±11 times, and p< 0.001). In human studies, there was no significance in reference vessel diameter and lesion length before the procedure between two groups. MLDs after LSRA+HSRA were significantly larger than those in HSRA (LSRA+HSRA= 1.22 ±0.16 mm, HSRA= 1.07 ±0.14 mm, and p= 0.0078), while MLAs after LSRA+HSRA tended to be larger (LSRA+HSRA= 1.79 ±0.51 mm2, HSRA= 1.55 ±0.47 mm2, and p= 0.19). There was no significance in the occurrence of in-hospital complication, including slow flow or no reflow, major dissection, and procedural myocardial infarction, between LSRA+HSRA and HSRA. Conclusions. LSRA can achieve larger lumen gain compared, whereas HSRA can pass calcified lesions easily. Combination of LSRA and HSRA is a safe and feasible strategy for severely calcified lesions in clinical practice.

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

“…Mizutani, et al reported that the greater debulking area following low-speed (< 150,000 rpm) was confirmed by OCT [ 37 ]. Yamamoto, et al also reported that the greater debulking area following very low speed (110,000 rpm) was confirmed by OCT [ 38 ]. However, Kobayashi, et al reported that there were no additional lumen gain following low speed (120,000 rpm) [ 39 ].…”

Orbital-Tripsy: Novel Combination of Orbital-Atherectomy and Intravascular-Lithotripsy, in Calcified Coronaries After Failed Intravascular-Lithotripsy

“…A combination of methods has been well described, including combination use of RA and IVL ( 9 , 10 ); however, in our case, despite the small MLA, the vessel size at mid-RCA estimated from segments adjacent to the most critical lesion was >3.0 mm, which may not be attainable by RA. There has been recent publication reporting the use of low-speed RA after high speed RA to achieve larger luminal gain ( 11 ), but our experience with this technique was not always as promising and may result in more no-reflow phenomenon. Hence, OA was chosen after careful intracoronary OCT imaging assessment for contraindication, such as grossly dissection lesions.…”

Additional ablation effect of low‐speed rotational atherectomy following high‐speed rotational atherectomy on early calcified in‐stent restenosis: A case report

“…Rotational atherectomy for native coronary calcified lesions is performed in the recommended range of 140,000–190,000 rpm; LSRA, defined as RA with a platform speed <140,000, has also been performed by some experts to acquire additional lumen gains 15 . Several reports showed that LSRA can achieve larger lumen gains in native coronary calcified lesions than HSRA 16,17 . In contrast, a retrospective study showed that LSRA did not demonstrate additional merits after sufficient HSRA 18 …”

“…15 Several reports showed that LSRA can achieve larger lumen gains in native coronary calcified lesions than HSRA. 16,17 In contrast, a retrospective study showed that LSRA did not demonstrate additional merits after sufficient HSRA. 18 These prior studies included a small sample size, and the debulking effect of LSRA remains controversial.…”

“…Although the total ablation time in LSRA following HSRA was longer than in HSRA alone, a previous study using an in vitro calcified model suggested that the potential mechanism for achieving larger lumen gain is the greater motion bias caused by burr deflection in LSRA rather than that in HSRA; the additional LSRA is expected to achieve further ablation effect. 16 Though the total ablation time was extended by the additional LSRA, we performed them after the confirmation of no further reduction of burr speed of HSRA. We determined that this additional effect by LSRA was derived from itself in our case.…”