Stentablation with Rotational Atherectomy for the Management of Underexpanded and Undilatable Coronary Stents

Successful double-layer metal stents rotational ablation under 2-dimensional and 3-dimensional optical coherence tomography guidance: a case report

“…Although excimer laser coronary atherectomy (ELCA) [ 4 – 7 ] and intravascular lithotripsy (IVL) [ 8 ] have been reported to be effective in the management of underexpanded and undilatable coronary stents, SA with RA is the only available interventional remedy to deal with intractable circumstances in most heart centers. In the past two decades, about 80 cases undergoing SA with RA have been published with excellent outcomes and minimal periprocedural complications [ 3 ]. However, there are only a few reports regarding SA for double-layer [ 9 ] or triple-layer [ 10 ] underexpanded stents using 2 burrs.…”

“…Recent data have demonstrated that intravascular imaging can provide additional information regarding lesion preparation, which results in higher rates of procedural success and better long-term outcomes, especially in complex lesions [ 3 , 11 ]. In most published cases of SA, intravascular ultrasound (IVUS) is the most common imaging modality utilized pre- and post-RA [ 3 ]. However, it is difficult to show the efficacy of RA in severely calcified plaques together with underexpanded stents in view of IVUS because ultrasound cannot penetrate the calcification and metallic struts.…”

“…Stent underexpansion, usually caused by inadequate lesion preparation in severely calcified coronary lesions, is strongly associated with long-term adverse clinical outcomes, including in-stent restenosis (ISR) and stent thrombosis [ 1 , 2 ]. Stent ablation (SA) with rotational atherectomy (RA) guided by intravascular imaging has been considered a bail-out strategy for the treatment of severe focal stent underexpansion associated with excellent periprocedural and in-hospital outcomes [ 3 ]. However, there are only a few reports have yet shown an SA procedure for double-layer metal struts under both 2-dimensional (2D) and 3-dimensional (3D) optical coherence tomography (OCT) guidance.…”

Use of rotational atherectomy for treatment of in-stent restenosis with coronary double-mesh stent underexpansion. Case report

“…5,6 The objective of the RA, in these cases, is not to completely remove the stent or plaque material, but to modify the lesion enough to enable the expansion of the already implanted stent, or to allow the newly placed stent to be fully expanded after balloon dilation. 4 Imaging tools, such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are of great help in the treatment of coronary lesions and stent underexpansion. These technologies can further clarify the nature of the lesion (whether more calcified or more fibrotic), its size and extent, providing greater accuracy in choosing the size and diameter of the stent, in addition to minimizing geographic losses.…”

“…4,[9][10][11][12] The RA procedure for stent ablation is still considered an off-label procedure, and there is a consensus that it should be performed only by experienced interventional cardiologists, with back-up surgical support for the treatment of potential complications. 3,4,13 Some technical recommendations are well established, such as initially using smaller diameter burrs, respecting an initial ratio of 0.6 between the burr and the vessel diameters; gradually increasing the size of the burr, if required; performing the ablations at a speed close to 150,000rpm; avoiding a direct ablation time longer than 20 to 30 seconds to prevent thermal injury; avoiding drops greater than 20,000rpm in speed to prevent the release of larger particles that may increase the risk of the no-reflow phenomenon. 13 It is worth mentioning that all these precautions have been taken when the procedure was conducted in the case of the reported patient.…”