Rotational atherectomy

Overview
Rotablation is used as a debulking device. It is generally not used as a stand alone device, and is generally used to facilitate greater lumen expansion via improving vessel compliance prior to stent placement. The procedure can be done in coronary arteries and in peripheral arteries.

Coronary rotational atherectomy
The device used in the coronary artery is called the Rotablator® Device. There are other devices as part of the system including the Rotablator® RotaLink® Advancer, RotaLink® Catheters, the RotaLink® Plus Pre-Connected Exchangeable System, RotaWire® Guide Wires and Rotaglide™ System Lubricant.

Indications

 * 1) The target lesion is in a native vessel, not a saphenous vein graft
 * 2) The target lesion is deemed to be undilatable by a balloon due to calcium or fibrosis.
 * 3) The target lesion is an ostial lesion
 * 4) The target lesion is located at a bifurcation and debulking is required to reduced the risk of plaque shift
 * 5) The target lesion could not be crossed with the primary device

Contraindications
The following are contraindications to the performance of coronary rotational atherectomy


 * 1) Ejection fraction < 30%
 * 2) Shock or hypotension
 * 3) The target lesion is the sole remaining conduit
 * 4) The presence of dissection. The patient should be managed conservatively for approximately four weeks to permit the dissection to heal before treating the lesion with the Rotablator system.
 * 5) Severe angulation at the target lesion
 * 6) An occlusions through which a guide wire will not pass
 * 7) The lesion is in a saphenous vein graft
 * 8) Angiographic evidence of thrombus

Strategies to reduce no reflow during the procedure

 * 1) Liberal administration of calcium channel blockers such as diltiazem (200 micrograms administered via the intracoronary route)
 * 2) Multiple short runs of rotablation
 * 3) A slower initial speed of rotablation such as 140,000 to 160,000 rotations per minute (RPM)
 * 4) Minimal deceleration during the bur runs
 * 5) Allowing a period of recovery between bur runs
 * 6) Avoid over-sizing the bur to minimize downstream embolization
 * 7) Use of a "Rotablator flush":
 * 0.9% NS 1000 cc
 * 10,000 Units of unfractionated heparin (10 units / ml)
 * Verapamil 10 mg (10 micrograms / ml)
 * Nitroglycerin 5 mg (5 microgams / ml)

Efficacy
The comparative efficacy of rotational atherectomy has been compared in the following studies / trials:

The ERBAC Trial
ERBAC was a single center trial in which patients with complex lesion were randomized to either balloon angioplasty (n=222), excimer laser angioplasty (n=232), or rotational atherectomy (n=231). The primary end point (procedural success defined as diameter stenosis <50%, absence of death, Q-wave myocardial infarction, or coronary artery bypass surgery) was higher among rotablation (89%) versus laser (77%) versus balloon angioplasty patients (80%, P=.0019). There was no difference in major in-hospital complications (3.2% versus 4.3% versus 3.1%, P=.71). Despite improved acute procedural outcomes, 6-month target lesion revascularization was more frequent in the rotational atherectomy group (42.4%) and the excimer laser group (46.0%) versus the angioplasty group (31.9%, P=.013).

The SPORT Trial
This trial Randomized 735 patients to bare metal stenting with or without prior rotational atherectomy. There were better acute procedural results among patients pre-treated with rotational atherectomy. There was no difference in TLR rates in follow-up