Rota ablation

Atherectomy: Rotablator®

Differential cutting

PTCA PRCA

Diamond

microchips

Rotablator®; Boston Scientific, Inc., Natick, Mass.

ROTA (Invented BY David Auth 1980

1st used for angioplasty by Reisman et al 1996)

Indications:• Calcified lesion

• Undilatable/chronic lesion

• Diffuse long lesion

• In-stent restenosis

• Bifurcation lesion

• Ostial lesion

• ? Small vessels (< 2.5

mm)(Mauri et al 2003)

Limitations:• Slow flow / No flow

• Perforation

• CK-MB release

• Spasm and dissection

• Technically challenging

• Heat generation

CONTRAINDICATIONS

• Acute myocardial infarction

• Thrombus containing lesion

• Saphaneous Vein Grafts

• Dissection

• Lesions at bend/tortuous vessels

• Extremely eccentric lesions

IMPORTANT TRIALS

• ARTIST(INSTENT RESTENOSIS)

• ROSTER(IN STENT RESTENOSIS)

• STRATAS(AGGRESSIVE STRATEGY)

• DART( ROTA IN SMALL CALCIFIED CORONARIES)

• SPORT(ROTA + STENT V/S STENT)

• ROTATAXUS (ROTA + STENT V/S STENT)

It is essential to use specific guiding catheters with sufficient support and

coaxial fitting.

TPI should be ready in case of RCA lesion

Slow burr advancement

To-and-fro pecking motion of the burr

Shorter burr run times (15–20 sec)

Lesion contact time of 1-3 seconds with longer 3-5 seconds of reperfusion

to allow debri clearance

30 seconds of burr rotation to be followed by 30 seconds of rest

Contrast injection during every rest interval

TIPS AND TRICKS FOR ROTA ABLATION

TIPS AND TRICKS CONTD….

1. Low burr speeds (140,000–150,000 RPM)

2. Strict avoidance of significant drops in rpm (> 5000 RPM for > 5

sec)

3. Flush the system with diluted contrast (1:10 dye-to-saline ratio)

during the ablation runs.

4. Keep systolic blood pressure > 100 mm Hg during the procedure

5. Keep the guidewire wet at all times to avoid friction

(Brown et al, 1997; Reifart et al, 1997; Whitlow et al, 2001; Dill et al,2000; Buchbinder et al, 2001; vom Dahl J et al, 2002; Goldberg et al, 2000):

1. GP IIB/IIIA infusion to be used in all cases unless contraindicated

2. Significant underestimation of vessel size can occur in the first 24

hours after rot ablation(Reisman et al)

3. IVUS use to guide therapy is recommended. Lesions with superficial

calcification are more suitable than those with deep calcification(IVUS

crossing the lesion is not possible in most cases)

4. Single burr debulking strategy is favored over multi burr strategy

(STRATAS Trial)

5. Burr To artery Ratio(<0.75)(STRATAS TRIAL)

6. Preferable to use DES(Moses et al 2003,Stone et al 2004,Khattab et al 2007, Benezet et al 2011.Pagnotta et al 2010,Mezilis et al 2010)

• During RotA, 500 ml of heparinised (5000 units) normal saline solution with

5 mg verapamil and 1000 μg nitroglycerine is administered locally, with a

view to preventing thrombus formation and vascular spasm, and avoiding

the no-reflow phenomenon.

• Ensure that the rotawire has no loops or kinks

• Change in the pitch of turbine noise may suggest resistance or friction to

burr.

• Avoid vasodilators during procedure to minimize hypotension risk.

• In bifurcation lesions Rotablation should be started at the most difficult to

wire branch first. Use low burr-artery ratios (<0.5) especially when there is

angulation present.

• In tortouus vessels Keeping the tip of the guidewire just beyond the lesion is

essential in order to reduce sidewall tension. Use undersized burr.

(Brown et al, 1997; Reifart et al, 1997; Whitlow et al, 2001; Dill et al,2000; Buchbinder et al, 2001; vom Dahl J et al, 2002; Goldberg et al, 2000):

From Williams MS. Circulation. 1998;98:742-748.

Activation of Platelets by Rotablation Is Speed-Dependent

ROTATIONAL ATHERECTOMY AND PLATELETS

Transmission electron

micrography:

• Platelet-rich plasma through chamber

with rota burr held stationary (0 rpm)

and stirred in an aggregometer for 5

minutes:

Intact platelet membrane, intracellular

granules, and clear background.

• Platelet-rich plasma was subjected to

rotablation at 180,000 rpm and stirred

in an aggregometer for 5 minutes:

Ruptured platelet membranes,

depletion of intracellular organelles

(“ghost platelets”),

and cloudy background.

From Williams MS, et al. Circulation. 1998;98:742-748.

Rotational Atherectomy and Platelets

Effect of Rotablation on Platelet Aggregation

Init

ial A

gg

reg

ati

on

Slo

pe

(un

its/m

in)

Rotablation Speed (rpm x 10-3)

Porcine blood exposed to a rotating burr resulted in: Platelet

aggregation and red blood cell crenation.

From Reisman M, et al. Cathet Cardiovasc Diagn. 1998;45:208-214.

• Predictors of CK-MB release:– deceleration > 5000 rpm > 5 sec

• Predictors of restenosis: – deceleration > 5000 rpm– LAD location– Multiburr strategy

STRATAS Trial (500 PTS RANDOMIZED TRIAL)

Whitlow PL, et al. Am J Cardiol. 2001;87:699-705.

%P = .008

Technique Matters: Incidence of Slow-Flow

Current optimal Burr-to-

Artery

Ratio (BA): 0.3-0.5 Aggressiv

e strategy (n = 249)

BA: > 0.9

Routine

strategy (n = 248)

BA: < 0.8

Slow-flow

Settings: • Long calcified lesions

• Total occlusion and right coronary artery

• Poor LV function and hemodynamic instability

• Thrombotic lesions (also post-MI)

• ? on -blockers

Technical modifications:• Small initial burr size and small upsizing

• Short ablation runs and avoid RPM drops ?Slow-speed

• Avoid hypotension and bradycardia

• Rota flush & GP IIb/IIIa inhibitors

• Treatment: verapamil, nitro, adenosine, nitroprusside, IABP

Rotational Atherectomy:

Complications

MECHANISM OF NO/SLOW-FLOW

• Atheromatous debris embolism

• Platelet and microthrombi

• Platelet activation, aggregation, lysis (by rota burr)

• Microcirculatory (vasculature) spasm

• Heightened microvasculature reactivity / tone

• Microcavitation

• Impaired local synthesis of EDRF

• Neuro-humoral reflex

• Lower epicardial vessel pressure and higher LVEDP

• Extreme cases: free radical injury, local edema,

microvascular plugging, no-reflow

Perforation

Settings:

• Lesion in a bend > 90

• Calcified lesion • Large burr-to-artery ratio• Total occlusion

Technical modifications:

• Smaller initial burr size (start with 1.25 mm burr)

• Bending the wire technique• Rota extra support wire • ?Predilatation with a smaller balloon• Avoid abciximab before rotablation

Rotational Atherectomy:

Complications

Complications

Mount Sinai Hospital Experience (6%-9% of PCI)

slow speed (140-150,000 rpm)

rotational atherectomy, BA: 0.4-0.5

short burr runs, rota-flush,

abciximab, stent, experience

---DES---

Rotational Atherectomy

%

Rota+BMS vs Rota+DES

Procedural ClinicalSuccess Success

%

MACE = major adverse cardiac events; TVR = target vessel revascularization

Data presented by Sharma S, et al. American College of Cardiology Scientific Sessions, Chicago, Ill, 2008

CK-MB 30-day Stent TVR>3x MACE Thrombosis

Procedural and Clinical Results

P = NS

P = .09P = .62

P = NS

%P = NS

P < .01

Rota + BMS (n =

284)Rota + DES (n = 130)

ROTATAXUS STUDYDENOVO CALCIFIED LESION EITHER OSTIAL,BIFURCATION OR LONG

240 PATIENTS ANGIOGRAPHIC FOLLOW UP FOR 9 MONTHS

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