tips and tricks of rotaablation

1. Rota ablation

2. Atherectomy: Rotablator®
Diamond
microchips
Differential cutting
PTCA
Rotablator®; Boston Scientific, Inc., Natick, Mass.
PRCA

3. ROTA (Invented BY David Auth 1980
1st used for angioplasty by Reisman et al 1996)
Indications:
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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:
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•
•
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Slow flow / No flow
Perforation
CK-MB release
Spasm and dissection
Technically challenging
Heat generation

4. CONTRAINDICATIONS
• Acute myocardial infarction
• Thrombus containing lesion
• Saphaneous Vein Grafts
• Dissection
• Lesions at bend/tortuous vessels
• Extremely eccentric lesions

5. IMPORTANT TRIALS
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•
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ARTIST(INSTENT RESTENOSIS)
ROSTER(IN STENT RESTENOSIS)
STRATAS(AGGRESSIVE STRATEGY)
DART
SPORT
ROTATAXUS (ROTA + STENT V/S STENT)
( ROTA IN SMALL CALCIFIED CORONARIES)
(ROTA + STENT V/S STENT)

6. TIPS AND TRICKS FOR ROTA ABLATION
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

7. 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)
:

8. 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)

9. • 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):

10. ROTATIONAL ATHERECTOMY AND PLATELETS
Activation of Platelets by Rotablation Is Speed-Dependent
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”),
From Williams MS. Circulation. 1998;98:742-748. and cloudy background.

11. Rotational Atherectomy and Platelets
Initial Aggregation Slope
(units/min)
Effect of Rotablation on Platelet Aggregation
Rotablation Speed (rpm x 10-3)
From Williams MS, et al. Circulation. 1998;98:742-748.

12. 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.

14. STRATAS Trial (500 PTS RANDOMIZED TRIAL)
Technique Matters: Incidence of Slow-Flow
• Predictors of CK-MB release:
– deceleration > 5000 rpm > 5 sec
P = .008
%
• Predictors of restenosis:
– deceleration > 5000 rpm
– LAD location
– Multiburr strategy
Aggressiv
e strategy
Routine
strategy
(n = 249)
BA: > 0.9
(n = 248)
BA: < 0.8
Whitlow PL, et al. Am J Cardiol. 2001;87:699-705.
Current optimal Burr-toArtery
Ratio (BA): 0.3-0.5

15. Rotational Atherectomy:
Complications
Slow-flow
Settings:
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•
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Long calcified lesions
Total occlusion and right coronary artery
Poor LV function and hemodynamic instability
Thrombotic lesions (also post-MI)
? on -blockers
Technical modifications:
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•
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•
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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

16. MECHANISM OF NO/SLOW-FLOW
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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

17. Rotational Atherectomy:
Complications
Perforation
Settings:
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Lesion in a bend > 90
Calcified lesion
Large burr-to-artery ratio
Total occlusion
Technical modifications:
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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

18. Rotational Atherectomy
Mount Sinai Hospital Experience (6%-9% of PCI)
%
Complications
---DES---
short burr runs, rota-flush,
abciximab, stent, experience
slow speed (140-150,000 rpm)
rotational atherectomy, BA: 0.4-0.5

19. Rota+BMS vs Rota+DES
Procedural and Clinical Results
Rota + BMS (n =
284)
Rota + DES (n = 130)
P = NS
P = NS
P < .01
P = .62
P = .09
%
%
P = NS
Procedural
Success
Clinical
Success
CK-MB
>3x
30-day
Stent
TVR
MACE Thrombosis
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

20. ROTATAXUS STUDY
DENOVO CALCIFIED LESION EITHER OSTIAL,BIFURCATION OR LONG
240 PATIENTS ANGIOGRAPHIC FOLLOW UP FOR 9 MONTHS

22. THANK YOU