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Successful percutaneous coronary intervention (PCI) by balloon angioplasty (BA) and stenting relies on the expansion of the atheromatous vessel and/or plaque fissuring. Calcified and fibrous atheromas resist balloon and stent dilatation, resulting in non-uniform expansion of eccentric lesions and under- or non-expansion in concentric lesions. The console controls and monitors the rotational speed of the burr and the turbine's gas supply. The compressed gas, foot pedal and advancer are all connect to the console. The black fibre optic cable from the advancer is connected to the front of the console. Connecting the drive shaft of the burr to the advancer requires the advancers drive shaft is exposed, by unlocking and fully sliding forward the black advancer knob. Increased platelet aggregability is associated with reduced coronary perfusion and symptomatic ischaemia. Balloon dilation of aorto-ostial stenoses is often complicated by incomplete balloon dilation and/or vessel recoil, particularly in calcified or fibrotic lesions.

Rotational atherectomy (RA) is widely used for treating calcified coronary lesions. Clinical data however remain limited.We assessed outcome and survival among patients undergoing percutaneous coronary intervention (PCI) with or without RA in the UK between September 2007 and March 2011.Data from 221,669 percutaneous coronary intervention (PCI) procedures were analysed; 2152 patients (0.97%) underwent RA (RA+); the remainder underwent conventional PCI (RA-). RA+ patients were older (71.7±9.6 vs. 64.1±12.8 year; p0.001), and had a higher incidence of diabetes (26.4% vs. 18.0%; p0.001), hypertension, (61.9% vs. 49.4%; p0.001), peripheral vascular disease (9.9% vs. 4.2%, p0.001), cerebrovascular disease (5.5% vs. 3.4%, p0.001), renal impairment (3.4% vs. 1.5%, p0.001) and poor left ventricular function (11.4% vs. 4.3%,p0.001). Procedural success was lower among RA+ patients (90.3% vs 94.6%; p0.001) and procedural complications were more frequent (9.7% vs 5.4%; p0.001). After 2.4±1.2 years follow-up, unadjusted Cox proportional hazard modeling demonstrated poorer survival for RA+ patients (HR 2.21, 95%CI 1.97-2.49; p0.0001). This disadvantage remained after adjustment for adverse variables (HR 1.26, 95%CI 1.11-1.44; p=0.0004) and following propensity analysis. There was evidence however of improved survival for RA+ patients with left main stem disease (HR 0.52, 95%CI 0.35-0.75, p0.0001), and peripheral vascular disease (HR 0.65, 95%CI 0.43-0.98, p0.0005).Rotational atherectomy was undertaken in patients with higher pre-procedural risk. Medium term survival was worse among patients undergoing rotational atherectomy, and this survival disadvantage remained after correction for available adverse factors. Rotational atherectomy however remains clinically useful for patients with calcified coronary lesions.

A 75-year-old woman underwent percutaneous coronary intervention (PCI) for her tight calcified lesion at proximal left anterior descending artery ([Figure 1A][1]). After debulking the thick calcified lesion using rotational coronary atherectomy, further dilation using a noncompliant balloon was

A nation-wide survey on the procedures and facilities of coronary revascularization, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) conducted by the Japanese Coronary Intervention Study (JCIS) group during 1997 revealed that PCI is more often used than CABG and is mainly carried out in low-volume facilities without surgical backup. The present study aimed to investigate the temporal changes in the usage of revascularization therapies and facilities from 1997 to 1999. A questionnaire was mailed in 1998 to the delegates of 1,086 PCI and 582 CABG facilities identified by the previous survey, and 89% of PCIs surveyed and 94% of CABGs surveyed reported back. The number of PCI procedures had increased by 19% from 97,831 to 116,479 and that of CABG procedures also increased by 21% from 16,374 to 19,846. The ratio of PCI to CABG was 5.9 in 1999, showing no significant change from 6.0 in 1997. In parallel, the number of PCI and CABG facilities increased from 888 to 941 and from 442 to 453, respectively. The use of coronary stents and other interventional devices increased during these 2 years. Coronary stents were used regardless of the annual procedural volume of the facilities, whereas other interventional devices, directional and rotational coronary atherectomy, were used mainly in the high-volume laboratories (p

A nation-wide survey on the procedures and facilities of coronary revascularization, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) conducted by the Japanese Coronary Intervention Study (JCIS) group during 1997 revealed that PCI is more often used than CABG and is mainly carried out in low-volume facilities without surgical backup. The present study aimed to investigate the temporal changes in the usage of revascularization therapies and facilities from 1997 to 1999. A questionnaire was mailed in 1998 to the delegates of 1,086 PCI and 582 CABG facilities identified by the previous survey, and 89% of PCIs surveyed and 94% of CABGs surveyed reported back. The number of PCI procedures had increased by 19% from 97,831 to 116,479 and that of CABG procedures also increased by 21% from 16,374 to 19,846. The ratio of PCI to CABG was 5.9 in 1999, showing no significant change from 6.0 in 1997. In parallel, the number of PCI and CABG facilities increased from 888 to 941 and from 442 to 453, respectively. The use of coronary stents and other interventional devices increased during these 2 years. Coronary stents were used regardless of the annual procedural volume of the facilities, whereas other interventional devices, directional and rotational coronary atherectomy, were used mainly in the high-volume laboratories (p

We report two cases in which the tips of guide catheters were damaged by rotational burrs during rotational coronary atherectomy of aorto-ostial lesions. There were no signs of embolization caused by the material of the guide catheters during and after the interventions.

To evaluate the mechanisms of lumen enlargement and the respective contributions of rotational coronary atherectomy (RA) and adjunctive percutaneous transluminal coronary balloon angioplasty (PTCA), serial measurements were recorded in 70 consecutive patients by quantitative coronary angiography before RA, after RA, after adjunctive PTCA, and 24 hours later. Minimal luminal diameter (MLD) increased from 0.85 +/- 0.31 mm to 1.42 +/- 0.27 mm (p < 0.001) after RA and to 2.20 +/- 0.46 mm (p < 0.001) after PTCA. Minimal luminal area (MLA) increased from 0.64 +/- 0.50 mm2 to 1.63 +/- 0.60 mm2 (p < 0.001) after RA and to 3.97 +/- 1.68 mm2 (p < 0.001) after PTCA. Both 24-hour MLD and MLA showed a trend toward reduced values (2.07 +/- 0.45 mm and 3.52 +/- 1.70 mm2, respectively) when compared with immediate results after PTCA. The absolute gains in MLD after RA and after PTCA were 0.56 +/- 0.24 mm and 0.79 +/- 0.38 mm, respectively (p < 0.01). The absolute gains in MLA after RA and after PTCA were 0.99 +/- 0.49 mm2 and 2.34 +/- 1.41 mm2, respectively (p < 0.001). The respective contributions of RA and PTCA are highly variable, but in general, balloon dilatation accounts for most of the gain in lumen area and therefore is not an adjunctive but a primary technique.

The clinical and angiographic outcome of patients undergoing rotational coronary atherectomy after unsuccessful balloon angioplasty was evaluated using quantitative angiographic methods to provide insight into this procedure's mechanism of benefit. During the study period, 41 patients (50 lesions) were referred for rotational atherectomy after standard balloon angioplasty was unsuccessful. After rotational atherectomy, percent diameter stenosis was reduced from 72 +/- 14% to 41 +/- 16% (p0.001); adjunct balloon angioplasty was performed in 44 lesions (88%), resulting in a 25 +/- 17% final diameter stenosis (p0.001). The acute gain in minimal lumen diameter was 1.20 +/- 0.59 mm. In lesions needing adjunct balloon dilatation, lesion stretch was 73 +/- 27%, and elastic recoil was 22 +/- 18%, with no variation by etiology of the initial balloon failure. Overall angiographic success (50% residual diameter stenosis) was obtained in 49 lesions (98%). Procedural success, defined as50% residual diameter stenosis and the absence of major in-hospital complications (death, Q-wave myocardial infarction or emergency bypass surgery), was obtained in 37 of 41 procedures (90%); complications developed in 3 patients (7%), including 2 who needed emergency bypass surgery after development of delayed abrupt closure. It is concluded that rotational coronary atherectomy may be used in selected patients when standard balloon angioplasty is unsuccessful. Its mechanism of benefit appears related, at least in part, to changes in plaque compliance resulting from partial atheroma ablation.

Transradial approach to coronary interventions is associated with improved patient outcomes. However, there is scarcity of studies evaluating the feasibility of radial approach to high-speed rotational coronary atherectomy (HSRCA) due to various technical reasons. Thus further studies are needed to

Percutaneous rotational coronary atherectomy (PRCA) is commonly used in the percutaneous treatment of diffuse, calcified coronary lesions in stable coronary syndromes (SCSs) and facilitates successful delivery and deployment of balloons and stents. Early experience with PRCA cautioned its use in acute coronary syndromes (ACSs). However, the evolution of the PRCA technique and improved antiplatelet pharmacotherapy has broadened its use in ACSs also. A total of 1,112 consecutive patients with an ACS (n=269) or SCS (n=843) who underwent PRCA of 1,483 lesions were examined retrospectively to evaluate the angiographic and short-term clinical outcomes. Troponin-I was elevated in 33.3% of the ACS group and in 0.6% of the SCS group at baseline (p0.001). Angiographic complications occurred more frequently in the ACS group (18.6% vs 13.1%, p=0.02). There was no difference in major complications between the groups (ACS 1.1% vs SCS 0.8%; p=0.44). The incidence of any periprocedural creatinine kinase-MB elevation was 17.1% versus 18.9% (p=NS) and 30-day major adverse cardiac events (death, disabling stroke, creatine kinase-MB3 times the upper limit of normal, urgent revascularization) was 5.9% versus 4.6% (p=NS) when comparing the ACS and SCS groups, respectively. With current techniques and antiplatelet therapy, PRCA can be safely performed in ACSs when lesion morphology dictates, with outcomes comparable to that achieved in SCSs. Although angiographic complications occurred more frequently in the ACS group, this did not result in a significantly higher incidence of postprocedural myonecrosis or 30-day major adverse cardiac events.

Rotational atherectomy uses the principle of high-speed abrasive differential cutting to ablate atheromatous plaque. This system, developed by David Auth, was approved for coronary use in 1993. Rotational atherectomy and other newer devices were designed principally to aid in the procedural success of percutaneous coronary intervention and potentially to reduce the occurrence of restenosis compared with that achieved with balloon angioplasty. Obviously, none of the newer devices (except for stents) have reduced the rates of restenosis, but rotational atherectomy may indeed be useful in certain lesion subsets in clinical practice. This chapter discusses the principles of operation, system and design characteristics, relevant clinical data, technical and procedural issues, and management of complications associated with rotational atherectomy.

Conventional balloon angioplasty in the elderly is associated with lower procedural success rates and a higher incidence of complications than demonstrated in younger patients. 1–4 The less favorable procedural outcome after balloon angioplasty in older patients has been attributed to the frequent presence of diffuse coronary lesions and the more complex anatomy noted in the aged population. 4 Rotational atherectomy, which partially ablates fibrocalcific plaque, has been beneficial in lesions in which conventional balloon angioplasty has failed, especially those with marked rigidity and elasticity. 5 As a result, rotational atherectomy may be particularly effective as an alternative to standard balloon angioplasty in selected elderly patients with symptomatic coronary artery disease. To evaluate the safety, efficacy and longterm clinical outcome of rotational coronary atherectomy in the elderly, we reviewed our experience with this procedure over a 2-year period.

In vitro experimental models of branch orifices jailed by various stents were created to estimate the safety and the efficacy of rotational atherectomy when rotational burrs were advanced through the struts of stents. The scaffolding structures of the stents were destroyed due to loss and deflection of the struts, and the size of ablated stent-particles differed: the maximal size was 1.7 mm in slotted stents, and 17.6 mm in coiled stents. Thus, there is a definite potential for ablating stents when rotational atherectomy of restenotic lesions of side-branch orifices jailed by stents is performed. (Jpn Circ J 1999; 63: 537 - 541)

Angioplasty of unprotected left main coronary artery lesions is associated with high procedural and late mortalities. We describe the successful use of rotational coronary atherectomy with prophylactic supportive measures in the management of a heavily calcified unprotected left main lesion. This report demonstrates that high-risk lesions, previously regarded as unapproachable, may be safely treated with newer technologies. © 1995 Wiley-Liss, Inc.

Rotational coronary atherectomy is an effective treatment for calcified ostial lesions. We report a case of guidewire transection during rotational atherectomy of a right coronary artery ostial stenosis. Guide catheter dislodgement appeared to have caused prolapse and kinking of the guidewire. Advancement of the burr over the kinked wire resulted in transection. The wire fragment was retrieved successfully using an inflated fixed-wire balloon catheter. This report illustrates the importance of excellent coaxial guide catheter alignment with rotational atherectomy and suggests that operators be vigilant to possible damage to the radiolucent rotational atherectomy guidewire. © 1995 Wiley-Liss, Inc.