Role of Rotational Atherectomy in Percutaneous Coronary Interventions in Elderly

Journal of Cardiology & Current Research

Introduction Case Report

Atherectomy(RA) was performed by Jerome Ritchie, Davide Volume 11 Issue 1 - 2018 More than 25 years have passed since the first case of Rotational and angioplasty has evolved tremendously with introduction of 1 differentAuth and coronary colleagues stents in 1987 [2,3], [1]. balloons Though and coronary wire, RA angiographycontinues to Consultant, Interventional Cardiology & Endovascular Intervention, Metro Hospitals and Heart Institute, India have an established role in treatment of complex coronary artery 2Director Interventional Cardiology, Metro Hospitals & Heart disease in the cardiac cath lab. It was initially introduced as an Institute, India alternative to balloon angioplasty but has now become an adjunct procedure during coronary intervention, especially of heavily *Corresponding author: Purshotam Lal, Director Interventional Cardiology, Metro Hospitals & Heart Institute, Noida, India, Email: calcifiedRA “debulks” or fibrotic the lesions. stenosis by physical removal of plaque, Received: | Published: 2018 devices like stents and balloons, hence increasing procedural September 28, 2016 February 16, success.causing plaqueIt is also modification. a useful in treatment This allows of “non delivery dilatable” of additional lesions where balloon angioplasty leads to incomplete lesion dilation prior to stent deployment [4]. coronary artery disease, the long-term results have not been very injury can increase the risk of peri-procedural myocardial encouragingThough the for procedure restenosis is andvery MACE. helpful Initially in treatment adopted of calcified in upto 14,000- 18,000) [7,8] with increased heat generation and thermal 10% of all percutaneous interventions (PCI), nowadays it is used The inelastic plaque gets ablated while the healthy arterial wall in only 3-5% of all cases [4]. infarctions and restenosis [7]. is unaffected. RA produces a smooth luminal surface and compared Procedure Descriptions to balloon angioplasty and does not produces micro-dissections RA is a debulking device that physically removes plaque and reduces plaque rigidity basically altering vessel compliance, duringin the calcified RA are smallerplaques than[9-11]. 10um The final(mean lumen diameter diameter of 5um) is larger and similar to that achieved by a dental drill. It works on the principle easilythat the traverse size of the the burr microvascularture that is used. Most to of be the absorebed particles creating by the RES [5]. In some cases, the microvasculature can be obstructed “non-compliant” tissue, while retaining the elastic arterial wall. of “differential cutting”, ablating only the calcified and fibrotic vasodilators, maintenance of arterial blood pressure, using small peckingcausing reducedmovements contractility, and preventing slow flow-no excessive reflow deccelarationsand MI. Use of “ablated”The hard andplaque calcified is broken plaque into is notparticles able to that deflect are thesmaller rota-burr than along with use of vasodilators are some of the techniques that can 5uMand gets in diameter ablated producingthat pass through microfissures the vasculature at the contact and zone.absorbed The by the Reticulo-Endothelial System [4]. reduceIt is theimportant incidence to ofbe slow-flow cautious /and no reflowuse meticulous [12,13]. technique The procedure entails a diamond encrusted elliptical burr that to prevent the risk of complications associated with use of RA. is rotated at high speeds (140,000-180,000 rpm) and advanced Some generally accepted best practices include a single burr with over a guidewire across the lesion [5]. The guidewire functions to keep the burr coaxial in the lumen of the artery. This is a nickel 150,000rpm, gradual burr advancement, short ablation runs of coated brass burr that is coated with 2000-3000 microscopic 15-20a burr secondsto artery and ratio avoidance of 0.5-0.6, of decelerations rotational speed of more of 140,000 than 5000 to diamond particles on the leading edge with a smooth trailing rpm. Indications edge. The diamond particles are 20um in size. The burr comes in In modern day practices, RA is a tool reserved for severe various sizes ranging from 1.25um to 2.5um and the burr size to be used is determined on the size of the vessel being treated [6,7]. failure, stent underdeployment, and some cases of instent It isThe recommended friction between to keep the burrburr to and artery the ration plaque of 0.5-0.6. produces restenosiscalcification [4]. when It is there useful is a for increased non-dilatable likelihood lesions of procedural – when varies depending on the decelerations of the burr. Short pecking inadequate balloon expansion is noted at the stenosis. In such movementsdeceleration are and recommended heat that can rangeas excessive from 2.6 decelerations C to 13.9C and(> lesions, RA at such sites prior to stent deployment facilitates stent

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delivery and expansion. An underexpanded stent increases the in cases of unexpanded stent and diffuse coronary artery disease risk of instent restenosis and thrombosis. (CAD). Absolute contraindications to RA include saphenous vein graft (SVG) lesion, in-situ thrombus, intimal dissection in or near target lesions and coronary artery occlusion where passage of and Oct (Optical Coherence Tomography) can precisely determine guide wire is impossible. Relative contraindications to RA include Newer imaging techniques like IVUS (Intravascular ultrasound) severe left ventricular (LV) dysfunction, lesion length 25 mm, lesion angulation and non availability of on-site coronary artery the location (superficial or deep) and extent of calcification bypass graft (CABG) surgery. ≥ [14]. Angiographically calcification can also be determined with cardiacradio-opacifications motion before noted contrast during injection cine-angiography. is termed Customarily, as “severe From 1st July 2015 to 30th calcification noted on both sides of the arterial wall without coronary angioplasties were performed in our center. Rotational June 2016, a total of 2,256 calcification” [15,16]. RA is an essential tool is treatment of such severe It also calcifications. increases procedural success in other complex lesions atherectomy was done in 181 patients; 82 patients were more like chronic total occlusions, ostial lesions and bifurcation lesions patientsthan 75 yearswhere old the age patients and 24 had patients undergone were moreone or than two 80 bypass years where the plaque morphology along with vessel geometry make of age. Out of 82 patients, 59 patients were ‘no-option’ CAD the procedure challenging [4]. them had associated comorbidites like chronic obstructive airway Syntax score is a angiographic tool used to determine the graft surgeries and were unfit for another surgery. A number of balloon angioplasty was not possible and aggressive medical a high syntax score (> 33), cardiac bypass surgery remains the treatmentdisease (‘bad failed lungs’), to relievechronic therenal intractable failure. In theseangina. patients Common the complexity of coronary artery stenosis [17]. In patients with group of patients who are not deemed suitable for cardiac bypass with bifurcation, diffuse disease and ostial lesions. However, RA surgerypreferred secondary treatment to optionother co-morbidities [17,18]. However – severe there COPD, remains repeat a wasindications also performed of RA were for calcified traditional lesions, contraindications critical left main to RA disease such CABG, very old age and overall frail status. Medical therapy remains an option for these patients however many such patients with thrombus) and in-stent restenosis. Complications with RA cannot tolerate high dose medical therapy secondary to the co- as SVG lesions, acute myocardial infarction (calcified lesions hypotension from nitrate and other anginals. We deem these included slow flow in several patients due to heavily calcified long patientsmorbidities as “Noeg: increasedOption” patients wheezing who from are betaneither blockers candidates in COPD, for lesions and were rectified with combination of intra coronary surgery nor respond well to medical therapy. These patients often withDilzem covered and NTG. stent. Burr Non entrapment paralytic stroke happened happened in one in onecase patient which withwas rectifiedspontaneous by taking recovery. the All whole patients system had out uneventful which was recovery dealt that also makes the coronary intervention very high risk. and were discharged 3-5 days later. On follow-up (ranging from have severe calcification compounded with a high syntax score We present below our personal experience in treating this 3 patients still complain of occasional Class II effort angina. Our 2-13 months) majority of patients are asymptomatic; however, difficult cohort. arteryexperience disease highlights associated the with fact comorbidities that ‘rota-stenting’ (unpublished is technically data) coronarySince 1990,atherectomy we have [20,21] experience and slow with rotational multiple atherectomy debulking (Figuresuseful in 1-4).difficult-to-treat patients with severe forms of coronary devices like extraction coronary atherectomy [19-21], directional from 1st July 2015 to 30th [19]. We describe our experience with Rotational Atherectomy Our Experience June 2016. In the initial days of the introduction of RA, it was used in ostial lesions as well. Those were the days before intracoronary stenting became popular. It was thought that RA would reduce the restenosis by preventing elastic recoil of the artery. One such case was a 48 years old male with RA for ostial lesion in left othercircumflex cutting artery; devices this was patient presented happened in the to beAnnual the first Conference case of RA of in India in the year 1991; our first clinical experience with RA and Figure 1:

Cardiological Society of India in 1992 and 1993 [20-22]. ostial left main A 78 coronary years old artery male (LMCA). with Class Fluoroscopy IV angina showed and LV extensive ejection balloon angioplasty/stenting is not possible (primary rotablation), fraction of 0.3. Cranially angulated AP view shows 95% stenosis of in casesLike other where centers, the conventional we use RA for method heavily ofcalcified balloon lesions crossing where or dilatation fails (secondary rotablation), for ostial lesions (mostly mmcalcification burr and involving deployment LMCA, of aLAD drug and eluting LCX. Correspondingstent from LMCA image to LAD. on the left main ostial lesions), for in-stent restenosis (for debulking), right side shows fully opened-up LMCA after ‘rota-stenting’ with a 1.5

Citation: DOI: Gupta S, Lal P (2018) Role of Rotational Atherectomy in Percutaneous Coronary Interventions in Elderly. J Cardiol Curr Res 11(1): 00372. 10.15406/jccr.2018.11.00372 Copyright: Role of Rotational Atherectomy in Percutaneous Coronary Interventions in Elderly ©2018 Gupta et al. 59/60

cath lab. Our experience also shows how it can be a essential tool toheavily treat calcifiedthe “No Option”complex patients coronary with arteries a high disease syntax in score the cardiac (> 33) who are not candidates for bypass surgery and not responding appropriately to medical therapy. With the aging population and complexity of co-morbidities this population will only increase.

burr appropriately. In the STRATAS trial, an aggressive burr to When using rotational atherctomy it is important to size the

artery size ratio (0.7-0.9) was compared to a moderate burr to Figure 2: artery ratio (less than .7). The aggressive group was noted to ejection fraction of 0.35 with Class III exertional angina. Cranially A 60 years old male with recent anterior wall MI and LV have a higher restenosis (58% vs 52%) and MI (11% vs 7%) [7]. SimilarAccording results to were some also studies noted thatin the have CARAT reported trial [6]. follow up for DES after RA, the rates of TLR within 1-2 yeas are < 10%. In angulated LAO view shows 95% stenosis of ostial left main coronary artery (LMCA). The ostial LMCA lesion was pulverized with a 1.5 mm some series, compared to BMS, DES also results in lower MACE imageRA burr on (Bostonthe right Scientificside shows International fully opened-up S.A., LMCA. France) over a 0.009” rates. This is primarily secondary to lower rates of Target Lesion RotaWire (Boston Scientific International S.A., France). Corresponding

Revascularization (TLR) [4,23-25]. Treatment for Complex Native Coronary Artery Disease) study The ROTAXUS (Rotational Atherectomy Prior to Taxus Stent vessels prior to DES implantation. There was no difference in MACEcompared in patients the effects who ofdid RA not on undergo moderately RA compared to severely to calcifiedpatients

whoHowever did receive these RA priorstudies to DEScompared implantation procedural [26]. and clinical success in cases with and without RA. In the high risk elderly cohort RA has not been compared to medical therapy. In patients who are at a prohibitive risk for cardiac bypass surgery either because of other co-morbidities, frail status or previous cardiac Figure 3: AP-cranial view. An 82 years old male presented with acute bypass surgery and not responding to medical therapy, coronary anterior wall MI. Coronary angiography revealed total occlusion of angioplasty and stent implantation remains the only treatment options. Given the increased angiographic complexity often found and LAD. The occluded segment was full of thrombus. LAD could not mid LAD. Fluoroscopy showed extensive calcification involving LMCA in this subset of patients, rotational atherectomy remains and

be opened-up despite repeated balloon inflations in progressively safely to facilitate the procedure. stent.increasing sizes. The right panel shows fully opened-up LAD after ‘rota- important tool and according to our experience can be utilized stenting’ with a 1.25 mm burr and deployment of a 2.5 mm drug eluting It is important to have exhausted medical treatment options so as to justify the intervention. It is also imperative to use meticulous technique to limit the risk of complications. Rotational atherectomy remains essential tool facilitating

our experience it remains a useful and safe tool in treating the “No Option”procedural patients success that in have treatment complex of coronarycalcified arterycomplex disease, lesions. high In syntax score and neither candidates for cardiac bypass surgery nor responding adequately to medical therapy. References 1. Rotational approaches to atherectomy and thrombectomy. Z Kardiol Figure 4: Caudally angulated RAO view of an 80 years old male showing Ritchie JL, Hansen DD, Intlekofer MJ, Hall M, Auth DC (1987)

2. Suppl 6: 59-65. extensive calcification involving distal LMCA extending into ostial LAD Bioresorbable scaffolds: rationale, current status, challenges, and deploymentand ostial and of proximal two drug LCX eluting (bifurcation stents lesion).(one from The LMCA right panelto LAD shows and Iqbal J, Onuma Y, Ormiston J, Abizaid A, Waksman R, et al. (2014) fully opened-up LMCA, LAD and LCX after RA with a 1.25 mm burr and 3. future.Iqbal J, Eur Gunn Heart J, JSerruys 35(12): 765-776.PW (2013) Coronary stents: historical second one in proximal LCX (covering its ostium). Discussion development, current status and future directions. Br Med Bull 106: 4. Tomey MI, Kini AS, Sharma SK (2014) Current Status of Rotational Rotational atherectomy remains an invaluable tool for treating 193-211.

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Citation: DOI: Gupta S, Lal P (2018) Role of Rotational Atherectomy in Percutaneous Coronary Interventions in Elderly. J Cardiol Curr Res 11(1): 00372. 10.15406/jccr.2018.11.00372