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 RotaglideTM System Lubricant.

# Indications
- The target lesion is in a native vessel, not a saphenous vein graft.
- The target lesion is deemed to be undilatable by a balloon due to calcification or fibrosis.
- The target lesion is an ostial lesion.
- The target lesion is located at a bifurcation and debulking is required to reduced the risk of plaque shift.
- The target lesion could not be crossed with the primary device.

# Contraindications
Contraindications to the coronary rotational atherectomy include:
- Severe left ventricular  dysfunction (ejection fraction < 30%)
- Shock or hypotension
- The target lesion is the sole remaining conduit
- 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.
- Lesion angulation in excess of 45o
- Occlusions through which a guide wire will not pass
- Saphenous vein graft lesions
- Angiographic evidence of thrombus
- Unavailability of bypass surgery
- Severe 3-vessel or unprotected left main disease
- Lesion length in excess of 25 mm

# Strategies to reduce no reflow during the procedure
- Liberal administration of calcium channel blockers such as diltiazem (200 micrograms administered via the intracoronary route)
- Multiple short runs of rotablation
- A slower initial speed of rotablation such as 140,000 to 160,000 rotations per minute (RPM)
- Minimal deceleration during the bur runs
- Allowing a period of recovery between bur runs
- Avoid over-sizing the bur to minimize downstream embolization
- Liberal use of a "Rotablator flush":
- 0.9% NS 1000 ml
- 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

# Complications of Coronary Rotational Atherectomy
Complications related to the use of coronary rotational atherectomy include major adverse cardiac events common to PCI such as stroke, myocardial infarction, and death as well as angiographic complications such as coronary artery spasm, perforation, coronary slow flow or no reflow phenomenon, transient vessel occlusion, and dissection. Burr entrapment is a rare and serious complication and often requires surgical or other bailout method for burr removal.

### Coronary Slow flow/No Reflow During Rotational Atherectomy
Several mechanisms are implicated in the development of no reflow phenomenon during coronary rotational atherectomy. Strategies to minimize the risks are as follows:
- Atherosclerotic debris and/or microthrombi embolism
- Smaller burr sizing
- Intermittent ablation with short runs of 15 to 20 seconds
- Avoidance of decelerations >5000 rpm
- Platelet activation and aggregation
- Optimal antiplatelet therapy, including use of a glycoprotein IIb/IIIa inhibitor such as abciximab
- Microcirculatory vasospasm
- Vasodilators
- Cocktail infusion of vasodilating agents such as adenosine, verapamil, and nitroglycerin has been used to reduce periprocedural complications. In addition to counteracting vasospasm, it may also enhance microvascular clearance by the reticuloendothelial system.
- Liberal use of flush solution

# 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)

## Coronary Atherectomy (DO NOT EDIT)