Drug-Eluting Stents and Rotational Atherectomy — “No ‘Roto’ Regret”

Available for over 20 years, rotational atherectomy continues to maintain a critical role in our armamentarium. Since it was first described, there were three major phases in its use: the pre-stent stage, the bare-metal stent stage and the drug-eluting stent stage. As we have learned more about its value, appropriate use and indications, the field of interventional cardiology has undergone a colossal transformation. Anticoagulation strategies have become more refined with weight-based heparin dosing regimens, the introduction of bivalirudin, a direct thrombin inhibitor, and our better understanding of the use of IIb/IIIa inhibitors. Our current use of dual antiplatelet therapy is much more sophisticated then in the early days of rotational atherectomy. In addition to device and pharmacological advancements, we continue to improve the field with current focus on bleeding complications, radial access and overall equipment “right-sizing”. Interventional cardiology equipment keeps undergoing rapid-cycle innovations and every few years our devices change. Rotational atherectomy has undergone only minor changes since its early days. So, where does this leave us in the current daily practice? In their current study, Schwartz and collaborators report their single-center results on 158 patients and 236 lesions in the period from 2004–2009.¹ In rotablation literature, this indeed is a large trial, particularly since it was performed in a single center.^2–6 The authors describe contemporary use in a tertiary referral hospital in the United States. These were elderly patients (mean age 72 years) with significant comorbidities (nearly half with diabetes mellitus) and high-risk features (nearly a third with severely depressed left ventricular function). The lesions that were intervened on were almost all classified as ACC/AHA B2/C and 80% were severely calcified. Importantly, 84% of interventions were planned rotablation procedures and only 16% were classified as “bail-out/non-planned” rotablation procedures. Overall angiographic success was 93% overall, 99% in the drug-eluting stent group, 95% in the bare-metal stent group and 63% in the no-stent group. The procedural complication rates were low: no-reflow was seen in 2%, perforation in 0.8% and hypotension/bradycardia in 3% of patients. One of the most valuable messages of this study is the technique the authors employed to achieve these excellent results. Two-thirds of procedures were accomplished with only one burr, and the average final burr size was 1.5 mm, with a low 0.6 final burr-to-vessel ratio. These data further confirm the state-of-the-art approach to rotational atherectomy — use of small burrs for plaque modification in highly calcified lesions to facilitate stent delivery and achieve adequate expansion and apposition. Nonetheless, rotational atherectomy has certain downsides. Fluoroscopy (30 minutes) and procedural times (96 minutes) were long and contrast use was high (212 ml). In-hospital mortality was 3.2%, with an overall MACE rate of 5.7%. The fact that the authors tackled some of the most complicated and sickest patients who likely would have been excluded from prospective multicenter trials likely contributed to these procedural and outcome characteristics. There are several areas that future research on the appropriate use of rotational atherectomy will have to address. The impact of radial access and reduction of access-related bleeding complications on outcomes has become one of the most germane areas of research in interventional cardiology.⁷ It is plausible that using radial access for rotational atherectomy may further improve patient outcomes. Interventional cardiologists will need to take a more proactive role in recognizing and managing patient and operator radiation exposure.⁸ Finally, in the current era of healthcare finance reform, the economic impact of using rotational atherectomy will need to be reexamined. The paper by Schwartz et al clearly demonstrates the immense progress in our understanding of how to address heavily calcified lesions in some of the sickest patients. It is a practical synopsis of contemporary rotational atherectomy use that incorporates nearly three decades of technological and pharmacological progress in interventional cardiology.

References

1. Schwartz BG, Mayeda GS, Economides C, et al. Rotational atherectomy in the drug-eluting stent era: A single-center experience. J Invasive Cardiol 2011;23:133–139.
2. Dill T, Dietz U, Hamm CW, Kuchler R, et al. A randomized comparison of balloon angioplasty versus rotational atherectomy in complex coronary lesions (COBRA study). Eur Heart J 2000;21:1759–1766.
3. Mauri L, Reisman M, Buchbinder M, et al. Comparison of rotational atherectomy with conventional balloon angioplasty in the prevention of restenosis of small coronary arteries: Results of the Dilatation vs Ablation Revascularization Trial Targeting Restenosis (DART). Am Heart J 2003;145:847–854.
4. Reifart N, Vandormael M, Krajcar M, et al. Randomized comparison of angioplasty of complex coronary lesions at a single center. Excimer Laser, Rotational Atherectomy, and Balloon Angioplasty Comparison (ERBAC) Study. Circulation 1997;96:91–98.
5. Whitlow PL, Bass TA, Kipperman RM, et al. Results of the study to determine rotablator and transluminal angioplasty strategy (STRATAS). Am J Cardiol 2001;87:699–705.
6. Safian RD, Feldman T, Muller DW, et al. Coronary angioplasty and Rotablator atherectomy trial (CARAT): Immediate and late results of a prospective multicenter randomized trial. Catheter Cardiovasc Interv 2001;53:213–220.
7. Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: A report from the National Cardiovascular Data Registry. J Am Coll Cardiol Cardiovasc Interv 2008;1:379–386.
8. Chambers EC, Fetterly KA, Holzer R, et al. Radiation safety program for the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2011;77:546–556.

———————————————————— From the Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois and Jesse Brown VA Medical Center, Chicago, Illinois. The author reports no conflicts of interest regarding the content herein. Address for correspondence: Mladen I. Vidovich, MD, FACC, FSCAI, 840 South Wood Street, MC 715, Chicago, IL 60612. E-mail: miv@uic.edu