Rotational Atherectomy in Coronary Arteries

Rotational atherectomy (RA) or rotablation is a highly specialized technique used to treat coronary atherosclerosis. A diamond/nickel-coated burr rotating at high speeds driven by compressed air allows vessel modification and ablates atherosclerotic plaque. The burr pulverizes calcific tissue to particulate matter, smaller than red blood cells, which are then processed by the reticulo-endothelial system. RA was developed to complement balloon-only angioplasty, which suffered significant restenosis rates. RA use was rationalized for debulking lesions, although not particularly selective regarding their complexity, but no clinical benefit was found using this approach. RA was rapidly recognized as an excellent tool for dealing with calcified plaques but, unfortunately, restenosis rates persisted with the use of bare-metal stents. The development of drug-eluting stents to tackle restenosis has contributed to the re-emergence and rising popularity of RA. When correctly used with modern techniques and appropriate training, RA offers a powerful tool in the arsenal against calcified disease, offering similar complication rates as conventional angioplasty. There has been an increase in demand for RA as the aging population is presenting with mature calcified coronary disease. RA offers a less invasive approach than coronary artery bypass graft surgery for treating these patients.