Intentional switch between 1.5-mm and 1.25-mm burrs along with switch between rotawire floppy and extra-support for an uncrossable calcified coronary lesion

Abstract

Rotational atherectomy (RA) is considered to be the last resort for a severely calcified coronary artery lesion. Severe complications such as vessel perforation or burr entrapment is closely associated with forceful burr manipulation during RA. The instructions for use of Rotablator (Boston Scientific, Marlborough, MA, USA) prohibit forceful burr manipulation when rotational resistance occurs. Nevertheless, RA operators tend to forcefully manipulate the burr if it cannot cross the lesion, because there has been no established strategy for an uncrossable lesion. We present a case with a severely calcified coronary lesion, which was uncrossable by a burr 1.5 mm with RotaWire Floppy (Boston Scientific). We intentionally switched 2 burrs (1.5-mm and 1.25-mm) and 2 RotaWires (Floppy and Extra-support) to cross the lesion. Uniquely, we downsized the burr (from 1.5-mm to 1.25-mm) initially for better penetration force, and upsized the burr (from 1.25-mm to 1.5-mm) finally for better contact to the calcification within the lesion. Our case suggests that 4 different types of combinations might work in a mutually complementary manner for an uncrossable calcified lesion. < Learning Objective: In rotational atherectomy, severe complications such as vessel perforation or burr entrapment are closely associated with forceful burr manipulation. We present a case with a severely calcified coronary lesion, which was uncrossable by a burr 1.5 mm with RotaWire Floppy. We intentionally switched 2 burrs and 2 RotaWires to cross the lesion. Our case suggests that 4 different types of combinations might work in a mutually complementary manner for an uncrossable calcified lesion.>

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

“…If an operator pushes the burr too much in the absence of speed down, there would be substantial risk of burr entrapment or vessel perforation. Therefore, an operator may change the RotaWires to facilitate the contact between the burr and the calcified plaques, switch to balloon dilatation (resultantly halfway RA), or rarely burr size-up to increase the contact area in the absence of reasonable speed down [ 56 , 88 ].

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Comparison of complications with a 1.25-mm versus a 1.5-mm burr for severely calcified lesions that could not be crossed by an intravascular ultrasound catheter

“…On the other hand, if operators have difficulty crossing the lesion with 1.25-mm burr, the next option is limited. Although upsizing to 1.5-mm burr may work for some lesions [9,11], upsizing is not a standard strategy for the lesion that cannot be crossed with the initial burr.…”

“…However, some severely calcified lesions do not allow intravascular imaging devices to cross before RA [9]. If lowprofile imaging devices cannot cross the lesion, the initial burr size should be either the smallest burr (1.25 mm) or the second smallest burr (1.5 mm) to avoid serious complications.…”

Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics: update 2023

“…If an operator pushes the burr too much in the absence of speed down, there would be substantial risk of burr entrapment or vessel perforation. Therefore, an operator may change the RotaWires to facilitate the contact between the burr and the calcified plaques, switch to balloon dilatation (resultantly halfway RA), or rarely burr size-up to increase the contact area in the absence of reasonable speed down [103,142].…”