Due to the expansion of percutaneous coronary intervention (PCI) indications to more challenging settings, the problem of referral of patients with complex and heavily calcified coronary lesions is growing. Despite the development of more supportive catheters, balloons, and alternative plaque-modifying technology, many calcified lesions may require rotational atherectomy (RA). However, universal adoption of the RA technique has been hampered by many factors such as concerns regarding the complexity of RA procedures and potential procedure-related complications, lack of standardised protocols, and lack of structured and widely available training programmes.
On the other hand, according to the data published in different studies and the widespread use of RA in the general population, current indications, complication rates, and outcomes inherent to RA have been changed and some of them should now be considered obsolete. In fact, despite the recommendations reported in its technical sheet, up to 50% of rotablations were performed in unstable patients for lesions that cannot be crossed by a balloon or adequately dilated before stenting. There are few data available regarding RA performed in acute coronary syndrome (ACS), and many of them were collected from subgroups of patients of other studies not designed for such a purpose. Thus, real-world data encourage us to study the role, safety, and usefulness of rotablation performed in ACS in a real scenario, in a controlled setting.
We conducted a prospective single-centre analysis of 78 consecutive patients with ACS in which RA was used to treat the culprit lesion. Demographic, clinical, angiographic, and PCI parameters were included and outcomes were collected.
The findings were as follows: Mean age was 77 years with a very high cardiovascular risk profile. Concomitant comorbid conditions were also high, as reflected by the prevalence of prior myocardial infarction and left ventricular ejection fraction dysfunction, present in 59% and 26% of the patients, respectively. Clinical onset was ST-segment elevation myocardial infarction (STEMI) in 36%, unstable angina or non-STEMI in 52%, and other causes such as cardiac arrest, syncope, or malignant arrhythmias in the remaining 12%.
Angiographic findings showed that the prevalence of multivessel disease was 70.2%, the left anterior descending artery being the most commonly diseased and the most frequently treated with RA, followed by left main disease.
PCI and RA procedures showed some interesting findings. Firstly, the majority of lesions were approached with a 1.5 mm burr with a mean rotational speed <140,000 rpm. Secondly, in 76% of rotablations a bifurcation was involved (22% of them were 1,1,1 according to the Medina classification). In accordance with current guidelines, drug-eluting stents were the most used, with a median stented lesion length of 60 mm.
The rate of achieved clinical and angiographic success was >98%. Cardiovascular death during hospitalisation was 1.2% (one patient, a cardiac rupture 4 days after primary PCI). No side-branch closures, burr entrapment, coronary perforations, or stent thrombosis were recorded. At 1.5-year follow-up the overall cardiovascular death was 3.8% (three patients, mainly due to heart failure) and target-lesion revascularisation rate was 2.4%.
In conclusion, currently RA is mainly recommended for preparation of calcified lesions in stable coronary ischaemic disease. However, in current daily practice the majority of patients referred for PCI are unstable patients. Our data support the use of slow-speed RA in combination with drug-eluting stents as an effective method to treat complex coronary lesions during ACS, even if a bifurcation is involved, with a low incidence of clinical and angiographic complications during index PCI and follow-up. Further study is therefore required.