Orbital and rotational atherectomy during percutaneous coronary intervention for coronary artery calcification

Abstract

Severe coronary artery calcification (CAC) increases the complexity of percutaneous coronary intervention (PCI) by inhibiting optimal stent expansion, leading to an increased risk of death, myocardial infarction, repeat revascularization, and stent thrombosis. Coronary atherectomy modifies and debulks calcified plaque to facilitate PCI. Although there is no clear consensus, and further studies are needed, the decision to perform atherectomy should be based upon the presence of fluoroscopic CAC or with the use of intravascular imaging. The management of CAC in the modern era relies on rotational and orbital atherectomy to prepare the lesion to facilitate stent delivery and optimal expansion. While the two technologies differ in equipment, technique, and mechanism of action, the available literature suggests similar efficacy and safety of the two systems, although head-to-head comparisons are limited. While rotational and orbital atherectomy have been shown to have excellent procedural success in terms of facilitating stent delivery, no system has been shown to reduce long-term major adverse cardiovascular events, although the definitive trial for orbital atherectomy has not been completed. Additional trials are needed to find the population who would derive the most benefit of atherectomy and to compare the two systems in a prospective manner.

Contemporary Approach to Heavily Calcified Coronary Lesions

“…This device uses the elliptical movement of a single-sized, eccentrically mounted crown to create centrifugal force, differentially sanding the hard component of the plaque and sparing the soft tissue component. [63] Comparing OA and RA highlights differences in structural components, mechanisms of action and different anatomical settings in which to use these devices:[64–66]…”

Clinical Outcome of Rotational Atherectomy in Calcified Lesions in Korea-ROCK Registry

“…With this current change, methods for modifying calcified coronary lesions have been more and more important (such as a non-compliant balloon, cutting/scoring balloon, orbital atherectomy, intravascular lithotripsy, and rotational atherectomy (RA)) [ 2 , 3 , 4 , 5 ]. The RA system is composed of a high-speed rotating diamond-coated burr that modifies calcified lesions.…”

Comparison of rotational and orbital atherectomy for the treatment of calcific coronary lesions: Insights from the VA clinical assessment reporting and tracking (CART) program

“…Coronary artery calcification (CAC) significantly increases the complexity of percutaneous coronary intervention (PCI), increasing the risk of procedural failure and periprocedural adverse outcomes such as coronary dissection, stent thrombosis, target lesion revascularization (TLR), and death 1‐7 . Several adjunctive therapies have been developed to improve procedural success by modifying calcific plaque in order to facilitate coronary artery dilation and subsequent stent placement 8 . The first therapy to be introduced was rotational atherectomy (RA), which uses a diamond‐encrusted elliptical burr rotating at high velocity to ablate hard plaque as it advances though calcified vessels 9 .…”