Rotational atherectomy: Technical update

Abstract

Percutaneous coronary intervention is currently the most common form of revascularization for symptomatic coronary artery disease. In elderly, diabetic and renal patients, there is an increased prevalence of calcified coronary disease. Rotational atherectomy (RA) can be useful in the treatment of these lesions.Plaque removal was initially proposed as an alternative to balloon angioplasty, hence RA required high-velocity protocols with large-sized burrs (over 2.0 mm). With a high incidence of acute complications and disappointing restenosis rates, the use of RA dwindled. However, the advent of drug-eluting stents, which significantly decreased the rate of restenosis, led to the repositioning of RA as an adjunctive technique in the preparation of densely calcified lesions, improving stent delivery and expansion.In recent years, a better understanding of the mechanism of action of RA has changed it from a plaque debulking to a compliance modifying technique. As a result, RA has become less aggressive, using smaller size burrs and lower rotational speeds. This conservative approach has improved immediate results, with increased safety and better long-term outcomes.In this review paper, the technique of RA is explained in the light of current knowledge.Aterectomia rotacional; Técnica de aterectomia rotacional; Aterectomia rotacional ---aspetos atuais da técnicaResumo A angioplastia coronária tornou-se a forma mais habitual de revascularização miocárdica na doença coronária sintomática. Na população mais idosa, nos diabéticos e nos doentes com insuficiência renal crónica, a prevalência de lesões calcificadas tende a aumentar. A aterectomia rotacional (AR) é uma técnica de grande utilidade no tratamento destas situações. 272P. Mota et al. Intervenção coronária percutânea; Calcificação coronáriaTendo-se considerado inicialmente que a erosão da placa podia constituir uma alternativa à angioplastia de balão, a técnica de aterectomia rotacional utilizava protocolos de alta velocidade com olivas que ultrapassavam os 2,0 mm de diâmetro. A ocorrência de complicações agudas e resultados insuficientes a longo prazo limitaram a sua difusão. O aparecimento dos stents com fármaco com redução significativa das taxas de reestenose, levou ao reposicionamento da aterectomia rotacional como técnica adjuvante na preparação das lesões permitindo uma melhor entrega e expansão dos stents, no contexto de doença aterosclerótica calcificada.Nos últimos anos, tem-se assistido a uma melhor compreensão do mecanismo de acção da aterectomia rotacional que passou de debulking para modificação de compliance da placa. Consequentemente, a técnica tem-se tornado menos agressiva: utilizam-se olivas de menor calibre, com menor velocidade de rotação, alcançando-se elevadas taxas de sucesso e de segurança no procedimento.Neste artigo procuramos reunir o conhecimento atual sobre como executar a técnica de aterectomia rotacional.

Reappraisal Value of a Modified Rotational Atherectomy Technique in Contemporary Coronary Angioplasty Era

“…IVUS images could also provide details on reference vessels or target lesions for safe ablation. Since debates on adequate burr/artery ratio and the "step-up" approach are still ongoing [1,2,20], this concise method could be convenient and efficient. irdly, the strategy of "high" speed to cross, followed by "low" speed to polish, was routinely applied to warrant efficient lesion cross the lesion and sufficient plaque modification, although evidence supporting a particular speed for RA is limited.…”

Cardiovascular Outcomes Following Rotational Atherectomy: A UK Multicentre Experience

“…This may reflect the use of relatively small burr sizes (≤1.75 mm in 85.5% of our cases), allowing the use of smaller calibre arterial sheaths and guiding catheters. Using smaller burr sizes reflects the contemporary use of RA where in modern intervention; RA is not just a debulking device, but also a modifier of calcific lesions, to allow balloon dilatation and optimum stent deployment . The planned use of a smaller sheath size is associated with less major femoral artery access bleeding and also increases the potential for transradial access, an established arterial access route with low access site bleeding rates .…”

Aterectomía rotacional coronaria en una lesión con reestenosis de stent subexpandido

“…Its primary mechanism of action involves a high-speed rotational plate ablation (140,000-160,000 revolutions per minute, rpm) and grinding by the diamond-coated abrasive bur. 5,6 RA is considered the standard technique for preparing highly calcified lesions before stent implantation, mainly when the lesions cannot be passed through with a balloon device. The success of the procedure was remarkably high (99.1%), with a relatively low rate of complications from dissection (7%), perforation (1%), or slow/no flow (1.1%).…”