Paul G. Yock

The changing role of high speed rotational atherectomy in the present and future practice of coronary intervention

Eight hundred and fifty-two high speed rotational atherectomy (HSRA) procedures were performed in a single consecutive series of 769 patients. Stand alone HSRA was performed in 261 patients (29%). HSRA with adjunctive low pressure (≤2 ATM) balloon angioplasty (LP BA) was performed in 261 patients (34%), and HSRA with adjunctive high pressure (≥4 ATM) balloon angioplasty (HP BA) was performed in 216 patients (28%). Prognostically unfavorable Type B2 and C lesions dominated the study group (73.8%). Procedural success rate was 96%. Emergency coronary artery bypass surgery was performed in 1.3% of cases, Q-wave myocardial infarction occurred in 3.0% and death, related to procedure, was consequent in 0.4% of cases. Incidence of flow limiting dissections was 3.1%, distal spasm 5.2%, and “no reflow” phenomenon, 1.7%. The recent technique modifications included continuous advancer/guiding catheter infusion of the nitroglycerin — verapamil mixture, limitation of duration of lesion engagement by the burr, decrease of rotational speed, and strict control of rpm drop during lesion ablation. Evolution of the interventional technique involved trends towards decrease of the use of HP BA in conjunction with steady increase in the percentage of SA and LP BA procedures over time. During the last year a combination of HSRA and stents emerged. The “rotastenting” produces excellent results in longer and more frequently calcified lesions than the use of stents alone with higher degree of attainable stent expansion. These technique changes resulted in complete absence of “no reflow” in last two years, as well as a decrease in coronary vascular reactivity from all burr passes.