Rotational atherectomy unveiled: Techniques, indications and patient selection

On Worl Heart Day 2023, Dr Praveer Agarwal, Executive Director-Interventional Cardiology, Fortis Escorts Heart Institute, New Delhi explains about rotational atherectomy which is a specialised procedure used in the treatment of heavily calcified coronary arteries

Cardiovascular diseases remain a leading cause of mortality and morbidity worldwide, with atherosclerosis being a common culprit. In the quest to manage severe cases of coronary artery disease, medical science has witnessed remarkable advancements in interventional cardiology techniques. One such advancement is rotational atherectomy – a procedure that involves the use of a high-speed rotational device to manage calcified plaque from within coronary arteries.

One-third of the total CAD cases show a high incidence of coronary artery calcification (CAC)^[1]. If left unattended, CAD and related clinical conditions like CAC can impose serious problems. Calcium is often a part of the plaque build-up in the arteries. If the calcified plaque becomes unstable, a blood clot may be formed, blocking the blood flow and oxygen supply to the heart. This can damage the heart muscles and can be fatal.

For effective management and treatment of CAC, rotational atherectomy ablates hard, inelastic, calcified plaque.

Understanding rotational atherectomy

Rotational atherectomy, is a specialised procedure used in the treatment of heavily calcified coronary arteries. Unlike traditional balloon angioplasty or stenting, where plaque is compressed against the arterial walls, rotational atherectomy employs a different approach. It involves a small, diamond-coated burr that spins at high speeds, effectively breaking down calcified deposits into tiny particles. These particles are then flushed out into the bloodstream.

Techniques involved in ROTA

 The procedure begins with the insertion of a guiding catheter into the coronary artery. Once in position, a flexible guidewire is threaded across the target lesion. The rotational atherectomy device, consisting of the burr mounted on a thin, flexible shaft, is then advanced over the guidewire to the site of calcification. As the burr rotates at speeds of up to 200,000 revolutions per minute, it grinds the calcified plaque into smaller particles.

When is ROTA recommended?

Rotational atherectomy is reserved for complex cases where traditional angioplasty or stenting may prove challenging due to severe calcification. Some key indications include:

Severe coronary calcification: When traditional interventions encounter extensive calcified deposits that hinder optimal stent deployment or expansion, rotational atherectomy can be considered.

Chronic Total Occlusions (CTOs): CTOs occur when an artery is completely blocked for an extended period. Rotational atherectomy can help prepare the artery for subsequent stenting in such cases as these lesions are fibrocalcific

Undilatable lesions: Lesions that do not respond adequately to balloon angioplasty alone may benefit from rotational atherectomy to ensure proper stent expansion and reduce the risk of complications.

Which patients are advised for the ROTA procedure?

Patient selection is crucial for the success of any interventional procedure. For rotational atherectomy, several factors come into play:

Calcium burden: The extent and distribution of calcification within the target lesion are key determinants. Lesions with moderate to severe calcification are more likely to benefit from rotational atherectomy.

Lesion length: Longer lesions that are heavily calcified pose greater challenges during stent placement. Rotational atherectomy can help facilitate optimal stent expansion in such cases.

Lesion location: Lesions located in areas where movement is relatively limited, such as at the ostium of a coronary artery, may benefit from plaque modification through rotational atherectomy.

Vessel size: The vessel’s diameter should be suitable for accommodating the rotational atherectomy device. Small vessels might not allow for safe device usage.

Patient’s clinical status: The patient’s overall health, including comorbidities and bleeding risks, should be evaluated to determine the appropriateness of the procedure.

Rotational atherectomy has emerged as a valuable tool in the interventional cardiologist’s arsenal, offering a unique approach to tackling heavily calcified coronary lesions. By employing high-speed rotation, this procedure effectively modifies and removes stubborn plaque, enabling successful stent deployment and improving overall patient outcomes. However, appropriate patient selection and meticulous technique execution remain paramount to achieving success. As medical technology continues to evolve, rotational atherectomy stands as a testament to the medical community’s dedication to finding innovative solutions for even the most complex cardiovascular challenges.

Reference

[1] https://journals.sagepub.com/doi/full/10.1177/26324636211013156