Step by Step Rotational Athrectomy

STEP BY STEP ROTATIONAL ATHRECTOMY, CALCIFIC CORONARY ARTERY DISEASES.

1. ROTATIONAL ATHRECTOMY Dr Virbhan Balai FNB Interventional Cardiology MSSH, New Delhi

2. STEP BY STEP ROTATIONAL ATHRECTOMY

3. TECHNICAL PERFORMANCE VASCULAR ACCESS AND GUIDE CATHETER SELECTION 6F is adeq . for RA in most pts, accommodating burr sizes up to 1.75 mm , and permitting either a transfemoral or transradial approach. Radial access is associated with rates of procedural success equivalent to those of femoral access and a radial-first approach need not be abandoned for cases in which RA is planned. Support can be further enhanced by use of a long sheath, supportive guide catheter or child-in-mother catheter. 7 French or larger may be needed in cases in which a 2.0 mm or larger burr is required or complex bifurcation PCI is planned. Some pt`s may be eligible for transradial access using 7F glide sheaths with a 6F profile or sheathless guide catheters with internal diameters up to 7.5F.

4. WIRING Position RotaWire across the target lesion with its tip placed as far distally as possible within the target vessel. Avoid small branches, loops and kinks in the wire  reduce risk of wire fracture and coronary perforation. In cases for which the microexchange catheter cannot cross the lesion, initial RA should be performed using the smallest (1.25 mm) burr.

5. RotaWire is available in 2 versions, Extra Support and Floppy. Both wires are 325 cm in length and 0.009 inches in diameter and taper to 0.005 inches before terminating in a 0.014 inches spring tip. Extra Support wire is more supportive, with a shorter taper (over 5 cm) and longer (2.8 cm) spring tip. Floppy wire is more flexible, with a longer taper (over 13 cm) and shorter (2.2 cm) spring tip. Rota wires lack coating and kink easily, requiring care in manipulation.

6. Extra Support wire causes more vessel straightening, wire bias, and ablation of plaque at the lesser curvature of angulated segments. Extra Support wire facilitate RA for aorto-ostial and distal lesions. Floppy wire is suitable for most cases , causes comparatively less vessel straightening and wire bias and permits more ablation of plaque at the greater curvature of angulations.

7. BURR SELECTION Maximum burr:artery ratio 0.4 to 0.6 Usually 1.5-mm burr for most epicardial vessels <3 mm in diameter & 1.75-mm burr for most epicardial vessels > 3 mm in diameter. Beginning with a 1.25mm burr  in cases where a microexchange catheter will not cross or for lesions with severe angulation , tortuosity , or eccentricity. Burr downsizing  if larger burr fails to crack a lesion or decelerates excessively. Burr upsizing  if lesion remains undilatable despite initial RA. Current OCT data goal of reducing calcium thickness to <500 microns to facilitate plaque fracture with balloons .

8. Burr Sizing

9. FLUSH SOLUTION Flush solution lubricate device motion, prevent sudden decelerations, and reduce heat generation. Pressurized flush solution is connected to the advancer and flows continuously through the sheath . Composition of the flush solution included heparinized saline, vasodilators, and RotaGlide lubricant. RotaGlide lubricant is associated with reduced heat generation in comparison with heparinized saline alone. RotaGlide is contraindicated in patients with allergies to egg or olive oil. Flush solutions without RotaGlide have been described with comparable procedural success .  

10. Vasodilators incorporated in flush solution to reduce risk of microvascular obstruction. Nitroglycerin, verapamil , nicardipine , adenosine, and nicorandil , in different combinations. Undesirable effects of these agents can include hypotension and bradycardia . At present time, standard flush solution composed of heparinized saline and RotaGlide is recommended, reserving vasodilators for provisional use .

11. ADJUNCTIVE PHARMACOLOGY Anticoagulation and antiplatelet - as per std. Glycoprotein IIb / IIIa inhibitors may be considered in cases for which high thrombotic risk outweighs bleeding risks .

12. Temporary Pacing Empirical transvenous pacemaker insertion was considered prerequisite for RA in the RCA, dominant LCX, or, in CTO of the dominant vessel, or in vessel providing major collateral circulation   - due to concern for risk of transient microvascular ischemia of the cardiac conduction system and associated AV block . Now, the routine practice of pacing for these scenarios has come into question, due to perceived diminished severity of distal embolization and microvascular ischemia with improved technique and reduced iatrogenic bradycardia with transition from routine to provisional use of vasodilators such as calcium channel antagonists.

13. Mechanical Circulatory Support RA in itself is not an indication for mechanical cardiac support. When temporary MCS is indicated for high-risk PCI, such support may permit more complete revascularization and greater operator comfort using RA. In a RCT comparing the Impella Recover LP 2.5 vs IABP for support of elective high-risk PCI, RA was used more extensively at operator discretion in subjects assigned to Impella support.

14. Atherectomy , Burr Motion, and Ablation Speed

15. Preparatory Steps for Rotational Atherectomy

16. Tips and Tricks Hold beta blockers 24 hours before procedure. Adequately hydrate the pt. preprocedure. TPI for RCA and dominant LCX. GC with simple curves and co-axial alignment to reduce wire bias. Avoid spring type Y connectors. Wire the lesion directly with Rota wire using torque device.

17. 7. Check DRAW D (Drip)- check drip from catheter sheath tip and beneath advancer. R (Rotation)- set the RPM at 18000 A (Advancer)- check free movement of advancer knob. W (Wire)- check wire clip is attached and tug on wire while rotating to ensure break is activated.

18. 8. Avoid activated burr advancement within the GC. 9. Beware of wire looping at the GC tip. 10. Platform the burr in a diseases free zone proximal to lesion. Ensure free flow of contrast beyond the burr. 11. Relieve any forward tension on drive shaft and guide wire. 12. Ablate the lesion with gentle pecking motion and moving forward only when there is light resistance. 13. Do not allow the RPM drop > 5000 from the platform speed. 14. Limit run to < 20 seconds. 15. Give enough time for the artery to perfuse in b/w the ablation runs. 16. Watch for slow flow, ECG changes, and Hypotension (keep atropine, vasopressors and vasodilators on the table). 17. Never advance the burr to the point of contact with spring tip (radio opaque point which is 0.014’’) 18. Do not keep the rotating burr in same position for long time. 19. Always withdraw the burr to the platform segment before stopping it. 20. Finish the polishing run (no rpm drop, no resistance).

19. Variations in burr motion and speed contribute to risk of complications - slow-flow/no-reflow and MI. Minimizes excessive decelerations/stalling , distal thromboembolization and thermal injury Visual, tactile and auditory feedback provide additional signals regarding resistance to burr advancement .

20. Fundamental elements of optimal RA tech. include :- Rotational speed of 140 000 - 150 000 rpm. Gradual burr advancement with a slow, pecking to-and-fro motion. Short ablation runs lasting no more than 20 seconds, pausing b/w runs. Avoidance of decelerations >5000 rpm.

21.   Key Elements of Optimal Rotational Atherectomy Technique

22. If a lesion cannot be crossed despite optimal technique , options to be considered include higher speeds, downsizing the burr, upgrading support using a more supportive guide catheter, or adding a child-in-mother catheter . For distal target lesions beyond the reach of the Rotalink advancer, the burr can be manually advanced to permit RA.

23. Procedure Completion and Device Removal Remove the burr by activating Dynaglide mode, pressing the brake defeat button, and manually withdrawing the burr while stepping on the foot pedal at low rotational speed. Once the burr has exited the body, cineangiography is indicated to assess the effects of RA and to exclude incident complications . Turn off the Dynaglide as this mode is causing a gas leak.

24. Post RA - Angioplasty and Stenting Workhorse guidewire is advanced across the lesion. Due to the calcific nature of lesions, NC balloons for post-RA balloon angioplasty. Contemporary DES should be considered the treatment following RA, sized 1:1 to the reference vessel diameter. IVUS/OCT may be a useful guide for optimal stent sizing.

25. RECOGNITION AND MANAGEMENT OF COMPLICATIONS Slow-Flow / No-Reflow Incidence: Decreased from 15% to 0.0% - 2.6% in more recent studies. It results from microvascular embolization of atherosclerotic debris and associated thrombi, platelet activation and release of vasoactive mediators . Harbingers of slow-flow / no-reflow include sudden decelerations and visual, tactile or auditory clues of high resistance to burr advancement . Larger burrs and higher speeds. Shorter time interval b/w ablation runs- causes slow flow.

26. Prevention  Optimal antiplatelet and anticoagulant therapy, continuous flush cocktail, and optimal technique. Treatment  Retraction of burr, correction of hypotension with fluids, vasopressors , and pacing if required; administration of i/c vasodilators, such as adenosine, nitrates, nitroprusside , nicardipine , and verapamil , ideally distally via a microdelivery catheter; and, if required, insertion of an IABP to augment coronary perfusion pressure .

27. Complications of Rotational Atherectomy in the Drug-Eluting Stent Era

28. DISSECTION Incidence of coronary artery dissection during RA ranges from 1.7- 5.9 %. Management  cessation of further RA; maintenance of true lumen wire position; and expeditious completion of PCI via balloon angioplasty and stenting .

29. NHLBI CLASSIFICATION OF CORONARY DISSECTION

30. PERFORATION Perforation  more severe variant of dissection in which disruption extends through the full thickness of the arterial wall. Incidence of perforation ranges from 0.0% - 2.0%  Lesion-specific predictors of perforation include. eccentricity, tortuosity , length >10 mm, and location in the RCA or LCX. Oversized burr and angulated lesion.

31. Management -early recognition and classification. Reversal of anticoagulation, prolonged balloon inflation, covered stent placement, and coil embolization , surgical closure and distal grafting.

32. ELLIS CLASSIFICATION OF CORONARY PERFORATION

33. Burr Entrapment Presence of diamond chips on the front, but not the rear , abets an opportunity for the burr entrapment. Once lodged and stalled within a lesion, retrograde ablation is not possible and friction associated with retrograde motion cannot be orthogonally displaced. In recent series, incidence of burr entrapment ranged from 0.5- 1 %. Relief of system tension before RA- key elements of prevention . In the event of entrapment; give NTG and try after some time Pull the RotaWire - taking advantage of the wire’s 0.014 inches spring tip- best tech. to remove the burr.

34. ‘ Kokesi ’ phenomenon : When performing rotablation at high RPM, frictional heat is generated and it may enlarge the space between plaque. In addition, the coefficient of friction when the burr is in motion is less than that at rest, which may facilitate the burr to pass the calcified lesion easily without debulking a significant amount of calcified tissue. Once the burr traverses the lesion, and the plaque cools the between the plaque is again reduced, and the ledge of calcium proximal to the burr prevents the withdrawal of the burr, which is known as ‘ Kokesi ’ phenomenon, a name given after a Japanese doll.

35. If this is unsuccessful , potential catheter-based solutions to facilitate burr retrieval include Balloon dilatation immediately proximal to the entrapped burr via the same or a second guide catheter. Deep GC or child-in-mother catheter coronary intubation and subintimal tracking and reentry with balloon dilatation adjacent to the entrapped burr . If burr retrieval is successful  surveillance is required for secondary complications including dissection and perforation. If retrieval is unsuccessful, cardiac surgery .

36. Several bailout techniques can be used to retrieve a trapped burr, but prior to proceeding forward. Assure patient is adequately anticoagulated (ACT >300) before attempting percutaneous retrieval. Administer intracoronary vasodilators to facilitate antegrade coronary flow and relieve possible spasm. Potential strategies for retrieval of an entrapped burr include the following: 1st: Manual traction of the rotablator system by pulling the burr, guidewire and/or guide catheter as a unit. This can be performed on or off Dynaglide . The vessel is at risk for perforation, dissection, and abrupt vessel closure  (AVC). In addition, the burr shaft can fracture. If you are pulling the burr and guidewire as unit (and not the guide catheter), remember to disengage the guide catheter to prevent injury to the coronary artery from it deep seating during traction. 2nd: Pass a second wire (hydrophilic-coated guidewire ) beyond the trapped burr, followed by balloon dilatation around the burr. This may alter the architecture of the calcified lesion and possibly free the trapped burr. However, a 4.3 Fr rotablation drive shaft sheath may prohibit introduction of a balloon catheter into the guide catheter (consider this possibility if using a 6 or 7 Fr guide catheter). To overcome this, use a two-catheter strategy (Ping-Pong technique) where a second vascular access is obtained and equipment necessary for burr retrival is introduced through. If a single guide catheter strategy is preferred, there are two options. On approach includes cutting the rota system near the advancer, and remove the sheath to expose the driveshaft surrounding the rota -wire. This approach makes room for introduction of a second guidewire and balloon. This approach is useful when using a 6 Fr guide catheter. Alternatively, you can upsize the access sheath and guide catheter to a 8 Fr. 3rd: Mother-child catheter technique can be used to wedge the burr and facilitate retrieval. The system is cut near the advancer, and the Teflon sheath is removed exposing the driveshaft which surrounds the rota -wire. A child catheter (monorail 5 Fr Guideliner or 5 Fr Guidezilla ) is inserted over the exposed drive shaft and positioned as close as possible to the entrapped burr. With simultaneous traction on the burr shaft and counter-traction on the child catheter, the catheter tip wedges between the burr and the surrounding plaque, exerting a larger and direct pulling force to retrieve the burr. 4th: Exclusion with a stent (As was done in this case). 5th: Emergent surgical retrieval should always be the last option for removing an entrapped burr, but is often required.

37. STRATEGIES TO PREVENT AND MANAGE COMPLICATION OF ROTATIONAL ATHRECTOMY

38. Rotational atherectomy is an endovascular procedure to ablate calcific atherosclerotic plaque. It is available for commercial use since past 3 decades . Use vary from <1% - > 10% at select centers.

39. Rotational athrectomy (RA, Boston scientific) consist of five component . Cylinder - provide cont supply of compressed air/N2 to console. Tank pr should be atleast 500PSI and pressure delivered to console should be b/w 90-110 PSI. Console – regulate the amount of air delivered to the advancer and inturn controls the rotational speed of burr. Foot pedal Advancer Guide wire

40. Mechanism of action Differential cutting Orthogonal displacement of friction Particles generated during ablation are about 5µ in size, cleared by reticuloendothelial system.

41. RotaPro Digital console and the elimination of the foot pedal

42. SCOPE OF THE PROBLEM AND RATIONALE FOR USE 1/5 pts undergoing PCI exhibits mod or sev coronary artery calcification . Calcified plaque; Procedural complications – Difficult stents and balloon delivery, Expansion -: underexpansion , asymmetrical expansion, malapposition . Postprocedural complications - increase restenosis , thrombosis . Severely calcified lesions ; high-pressure inflation of a NC balloon may fail to dilate a stenosis despite angiographic appearance of complete balloon expansion . Asymmetrical calcification predisposes to dissection or perforation .

43. Intimal calcification ; correlates with comorbidities ,- advanced age, DM, CKD.

44. Two RCTs inform the current approach. STRATAS (Study to Determine Rotablator and Transluminal Angioplasty Strategy) compared: - Aggressive strategy (maxi burr:artery ratio >0.70 or with adjunctive balloon inflation ≤1 atm ) Vs routine strategy (maxi burr:artery ratio ≤0.70 with routine balloon inflation ≥4 atm ). Aggressive strategy yielded no advantages for clinical success, final MLA, or residual stenosis , and higher rates of periprocedural CKMB release and TLR at 6 months.

45. CARAT (Coronary Angioplasty and Rotablator Atherectomy Trial) also showed no benefit with aggressive strategy for procedural success or TVR at 6 months, and indeed found higher risk of angiographic complications with a larger burr:artery ratio.   Catheter Cardiovasc Interv .  2001;53:213–220. Transition in RA practice away from aggressive debulking has permitted use of smaller burrs, sheaths, and guide catheters with improved safety and equivalent efficacy .

46. PATIENT AND LESION SELECTION MAIN INDICATION- Modification of severely calcified coronary lesions. Randomized trials in both the BMS ( COBRA study ) and DES ( ROTAXUS trial ) eras have not shown reduction in long-term ischemic events with routine use of RA, Use of RA in severely calcified lesions is associated with greater acute diameter gain, greater luminal CSA, and less final residual stenosis after stent deployment .

47. Grading of coronary artery calcification is primarily based on fluoroscopic findings Can be enhanced by use of intravascular imaging. On fluoroscopy, coronary calcification is radio-opaque, Severe calcification described as radio-opacities noted without cardiac motion before contrast injection, generally involving both sides of the arterial wall.

48. IVUS ; coronary calcification shadow deeper arterial structures with an acoustic signature that is brighter than the reference adventitia; Severe calcification is characterized by a large arc of superficial calcium involving 3 or 4 quadrants.

49. OCT ; coronary calcification appears as a well-delineated signal-poor region with sharply defined borders. OCT ; Plaque calcium predictive of stent underexpansion — maximum angle >180°, maximum thickness >0.5 mm, and length >5 mm indicate lesions more likely to benefit from an atheroablative strategy.

50. Multimodality invasive assessment of coronary plaque calcification

51. Contraindications and Cautions RA cannot be used for occlusions through which a guidewire will not pass, (although cases of CTO have been described) Not recommended for routine use in degenerated SVG graft lesions or thrombus . Dissection is not an absolute contraindication and RA can be cautiously applied for the purpose of plaque modification provided that wire position remains in the true lumen. Lack of available cardiac surgery or pt ineligibility for CABG surgery is a relative CI to RA. Pt and lesion features prompting caution in use of RA include severe LV dysfunction , severe multivessel or unprotected LMCA disease , lesion length >25 mm, and lesion angulation >45 ° .

52. Special Situations Ostial and Bifurcation Lesions Plaques localized at arterial ostia and bifurcations can be bulky, predisposing to plaque shift, acute side branch closure, and suboptimal stent delivery and deployment. In such cases, lesion modification with RA can be beneficial, with favorable long-term outcomes. For aorto-ostial lesions, care should be taken to ensure coaxial alignment of the guide catheter and RotaWire and to avoid wire loops.

53. Bifurcation lesions in which severe calcification is confined to the main vessel may be adequately treated with main vessel RA alone. Lesions with severely calcified, balloon- uncrossable or nondilatable plaque in a major side branch >2.5 mm in diameter may benefit from side branch RA. During performance of RA, only the RotaWire should be present in the target vessel so as to avoid cutting other wires . Sequence of side branch and main vessel RA should be determined with attention to avoiding acute closure and loss of access to the unwired vessel. Following completion of RA, both main vessel and side branch should be rewired with completion of PCI according to vessel sizes and convention for bifurcation stenting .

54. Left Main Disease RA can be performed safely and with favorable effect.

55. Chronic Total Occlusion RA can facilitate PCI of CTO provided passage of the crossing wire through true lumen. Can follow initial balloon angioplasty. If a balloon angioplasty catheter cannot cross the lesion, however, RA can be used as an initial intervention.

56. Aortic Stenosis With Plan for TAVR Experts have suggested that pre-TAVR PCI of the LM or prox LAD may be reasonable. Calcified lesions are common in candidates for TAVR and when appropriate, RA can be safely performed in elderly pt`s with sev AS. Coronary angio and intervention can be technically challenging after TAVR, in particular with valve types that overlie the coronary ostia .

57. Renal Insufficiency CKD is associated with accelerated progression of coronary artery calcification. Caution in usage of contrast medium is appropriate in these cases to reduce risk of AKI. When compared with a nonatherectomy approach, RA is not associated with significant difference in contrast usage . In the ROTAXUS study (Rotational Atherectomy Prior to TAXUS Stent Treatment for Complex Native CAD), pts undergoing RA (of whom 4.2% had chronic renal failure) received an average of 201.0±113.6 mL of contrast medium .

58. DEVICE SELECTION Atherectomy devices - modify plaque via physical removal of plaque material. Nonatherectomy devices - modify plaque via cutting or targeted dissection. Orbital atherectomy vs RA have found similar incidence of MACE at 30 days and 1 year.   Am J Cardiol . 2017;119:1320–1323. Coronary lithoplasty modify plaque via calcium fracture . JACC Cardiovasc Imaging. 2017;10:897–906.

59. Interventional Devices to Modify Calcified Coronary Lesions

60. HALF WAY ROTATIONAL ATHRECTOMY Halfway  RA is a novel strategy, in which an operator does not advance the burr to the end of a continuous calcified lesion, and performs balloon dilatation to treat the remaining part of the calcified lesion. There was no burr entrapment or vessel perforation following halfway RA.

61. WHO SHOULD PERFORM RA? Expectations for Operators Highly operator and tech. - dependent outcomes of RA For interventional cardiologists wishing to become independent RA operators: Device-specific training, including coursework, simulator-based experience, and a minimum of 5 proctored cases. Minimum volume of PCI to establish competency. Continuing medical education, focused on advances in PCI tech. technologies, quality, and safety.

62. Expectations for Institutions Excellent outcomes of RA rely on not only the skills and knowledge of the operator but also importantly on the preparedness and teamwork of cardiac catheterization laboratory staff. For facilities interested in building and maintain an RA program, we would advocate: Device-specific training and certification for nurses, technologists, and midlevel practitioners focused on knowledge of equipment, standardization of protocols, and preparation for emergencies; Redundant , current, readily accessible equipment required for acute management of RA emergencies, including but not limited to covered stents, embolization coils, and pericardiocentesis trays ; Min. Volume of PCI to establish competency. Cardiac surgery available on-site or immediately available via interhospital transfer.

63. CONCLUSIONS RA is an operator and team-dependent procedure that with careful tech. can facilitate optimal PCI for calcified coronary lesions with a high degree of efficacy and safety . Standardization of best practices may help to improve outcomes of RA and improve availability of high-quality RA for pt`s in need.

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