Rotablation - An overview
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The document is a comprehensive review of rotablation, an endovascular technique introduced 30 years ago for treating obstructive atherosclerotic disease, particularly in heavily calcified lesions. It discusses the principles, indications, contraindications, equipment, techniques, potential complications, and the current role of rotablation in percutaneous coronary interventions. While it is infrequently used today, rotablation remains relevant for specific clinical scenarios where conventional methods may fail or produce suboptimal results.
Rotablation - An overview
- 2. INTRODUCTION
- 3. WHAT WE’RE GOING TO DISCUSS • Principles • Indications Contraindications • Equipment and Technology – ROTABLATOR TM (Boston Scientific) • Do’s, Don’ts; Tips and Tricks • Complications • Current Status of Rotablation • Conclusion
- 4. INTRODUCTION • Introduced 30 years ago by Jerome Ritchie, David Auth, and colleagues • For the endovascular treatment of obstructive atherosclerotic disease • Initially explored as an alternative to balloon angioplasty • RA proved complementary to stenting of complex lesions, especially heavily calcified lesions
- 5. INTRODUCTION • Use is infrequent today • But maintains relevance in the Cath lab
- 6. PRINCIPLES
- 7. PRINCIPLES • Physical removal of plaque and reduction in plaque rigidity, facilitating dilation • Rotablator ablates plaque using a diamond encrusted elliptical burr rotated at high speeds (140,000 to 180,000 rpm) by a helical driveshaft that advances gradually across a lesion over a guidewire
- 8. PRINCIPLES • Burr preferentially ablates hard, inelastic material, such as calcified plaque, that is less able to stretch away from the advancing burr than healthy arterial wall • This is referred to as “differential cutting”
- 9. PRINCIPLES • Guidewire helps to keep the burr’s abrasive tip coaxial with the lumen • Wire bias in highly tortuous or angulated segments may predispose to dissection or perforation • Guidewire should be positioned Distal to the target lesion in the largest distal vessel, Avoiding small side branches and distal narrow vasculature, Avoiding bends, kinks, or loops
- 10. PRINCIPLES • Balloon angioplasty tends to produce intimal splits and medial dissections in calcified lesions • RA yields a relatively smooth luminal surface with cylindrical geometry and minimal tissue injury
- 11. PRINCIPLES • Lumina are not always cylindrical after RA • In regions of tortuosity or eccentric plaque, crater or gutter formation can occur - Referred to as lesion bias • This may impede stent deployment OR yield lumen enlargement greater than burr size
- 12. PRINCIPLES • Thermal injury may contribute to increased risk of periprocedural myocardial infarction (MI) and restenosis associated with excessive decelerations • Modern technique, favoring gradual, intermittent ablation with a pecking motion, and slower RPMs (140,000 – 150,000) aims to minimize decelerations and thermal injury
- 13. PRINCIPLES • RA particulate must traverse coronary microvasculature before clearance by the RES • Microvascular obstruction can cause reduced contractility in myocardium, slow-flow/no-reflow, and MI • Most particles are small enough to readily pass; 98% are <10 mm, with a mean diameter of 5 mm (smaller than normal mature erythrocytes)
- 16. INDICATIONS 1. Heavily calcified lesions (HCCL) - localized or extended 2. Presence of a circumferential calcium ring where the lesion is undilatable by balloon angioplasty From Petros S. Dardas. Rotablation in the Drug Eluting Stent Era. INTECH Open Access Publisher; 2012.
- 17. INDICATIONS 3. Ostial lesions with severe fibrosis with or without calcification 4. Balloon-inaccessible lesions, provided that the Rotawire can cross the lesion 5. Failed PCI is either due to inability to cross the lesion or dilate 6. Bifurcation lesions 7. CTO - inability to cross with a balloon catheter From Petros S. Dardas. Rotablation in the Drug Eluting Stent Era. INTECH Open Access Publisher; 2012.
- 18. CONTRAINDICATIONS 1. Occlusions through which guidewire will not pass 2. Last remaining vessel with compromised LV function 3. Coronary dissection 4. Evidence of thrombus 5. Severe tortuosity 6. Relatively contraindicated in vein grafts (increased risk of dissection and distal embolization)
- 27. ROTABLATOR SETUP
- 28. TIPS AND TRICKS
- 29. CASE SELECTION • Treating certain types and/or locations of lesions or patients with certain conditions is inherently riskier • Important to be aware of the higher risk when treating such patients and the lack of scientific evidence for treatment in 1. Patients who are not candidates for coronary artery bypass surgery 2. Patients with severe, diffuse three-vessel disease (multiple diseased vessels should be treated in separate sessions) 3. Patients with unprotected left main coronary artery disease 4. Patients with ejection fraction less than 30% 5. Lesions longer than 25 mm 6. Angulated (≥ 45°) lesions. There has been limited experience with the brachial approach
- 30. CASE SELECTION • The decision to use rotablation should be made early, before large dissections appear
- 31. GUIDE CATHETER SELECTION & SIZING
- 32. GUIDE CATHETER SELECTION & SIZING • Preferable to use guides with side-holes to improve flow through the vessel • Guide must be co-axial to the vessel to avoid wire bias • Use a guide size that will accommodate the final burr to be used (if stepped approach is planned) • Avoid guides with abrupt primary and secondary curves
- 34. BURR SELECTION • Ideal Burr to Artery ratio of 0.6/0.7 : 1.0 • A stepped approach and gradually increasing burr size is ideal when multiple burrs are required • This ensures smaller size of particles generated, lesser decrement in RPMs while ablating and reduces chances of the burr getting embedded in the lesion (nightmare in the lab!)
- 35. WIRE SELECTION • To cross the lesion, use a workhorse wire and exchange for Rota wire with a OTW catheter • Finish the intervention on a workhorse wire • Ensure that the Rota wire is not kinked • Between the Rota wires, the stiffer wire produces unfavorable bias sometimes; Though this bias can sometimes be used to advantage in angulated lesions
- 36. WIRE PRECAUTIONS • Always ensure that the guide wire is visible proximally • Watch the tip • Ensure beforehand that the wire clip torquer is on - it prevents the guidewire from spinning when brake defeat is activated
- 37. WIRE PRECAUTIONS
- 38. TEMPORARY PACEMAKER • Prophylactic temporary pacemaker is commonly used with rotational atherectomy of the LCx or RCA • Protects against the risk of complete temporary A-V block
- 39. TIPS AND TRICKS • Testing the System When testing the rotation, ensure not to allow the rotating burr to come in contact with exterior surfaces (towel, tray table etc.) Never operate the Rotablator Advancer without saline infusion Flowing saline is essential for cooling and lubricating the working parts of the advancer Operating the advancer without proper saline infusion may result in permanent damage to the Rotablator advance
- 40. TIPS AND TRICKS • Advancing the burr : Advance the non-activated burr to reach the lesion Dynaglide is not recommended for advancement because the rotational speed does not fall when resistance is met Dynaglide is a control that sets the rotation speed at 50.000-90.000 rpm and is used for reducing friction when removing the device
- 41. ABLATION • 3 S Slow Smooth Short Representative video in a training model
- 42. ABLATION • Do not push the rotablator into the lesion • Use “Pecking” technique • Avoid crossing the entire lesion during the initial passage • Pecking” motion prevents “trenching” into arterial wall, allows wire to reposition as vessel compliance changes with debulking • Ablation is best performed in 15 second runs
- 43. ABLATION PRECAUTIONS • During the ablation, excessive deceleration (>5,000 rpm) must be avoided Results in improper ablation and increases the risk of vessel injury, formation of large particles, and ischemic complications related to excessive heat generation • Avoid stopping or starting the burr in the lesion • Avoid stopping burr distal to lesion • Avoid adjusting rpm's during ablation • Avoid keeping the burr in one position while rotating at high speeds • Avoid advancing rotating burr to the spring tip (radiopaque) tip of the wire • Avoid burring in the guide catheter
- 44. ABLATION • In case Rotablation is planned at two tandem lesions, the position of the platform will have to been changed after ablating at the proximal lesion Representative video in a training model • To do so, hold the black advancer knob in place, while your assistant advances the platform itself, the burr stays in position
- 45. ROTAFLUSH - COCKTAIL • CARAFE study (Cocktail Attenuation of Rotational Ablation Flow Effects) • Showed that use of local irrigation with a cocktail of normal saline with heparin 20U/ml, verapamil 10 mcg/ml, NTG 4 mcg/ml through the 4F sheath of the advancer virtually eliminates “Slow Flow” and “No-Reflow” phenomenon • However some operators feel this produces hypotension and may not be appropriate in patients with LV dysfunction too
- 46. FEEDBACK DURING ABLATION • Visual Monitor decelerations – drop in RPM from pre-set desired RPM while resistance is met Smooth advancement under fluoroscopy Contrast injection to discern lesion contours and borders • Auditory Pitch changes relative to resistance encountered by burr • Tactile Advancer knob resistance Excessive drive shaft vibration - excessive load on burr advanced too rapidly
- 47. ABLATION- FINAL RUN • Finish with one polishing run • With no drop in rpm • And no resistance Representative video in a training model
- 48. REMOVAL OF THE BURR CATHETER Representative video in a training model • Dynaglide is a control that sets the rotation speed at 50.000-90.000 rpm and is used for reducing friction when removing the device
- 49. COMPLICATIONS
- 50. COMPLICATIONS • STUCK ROTABLATOR • Advancer stops • Stall light lights up • Slow Flow / No Reflow • Perforation
- 51. STUCK ROTABLATOR • Entrapment of rotablation burr or trapped rotablator occurs rarely (0.6% incidence) • Dreaded complication • Small burr can be advanced beyond a heavily calcified plaque before sufficient ablation, especially when the burr is pushed firmly at high RPMs • Burr can also be entrapped within a severely calcified long lesion, especially angulated and concomitant coronary spasm
- 52. STUCK ROTABLATOR – WHAT TO DO? • STEP 1 : Pray Hard • STEP 2 : Keep calm • Simplest method to retrieve the entrapped burr is pulling back the rotablator system manually • Some cases the stuck burr can be withdrawal successfully by manual traction with on-Dynaglide or off-Dynaglide rotation
- 53. BUT.. • Vessel may be injured (proximal segment) if the guiding catheter gets pulled in too deep • Guiding catheter can be disengaged and another wire kept in the aorta to inadvertent avoid deep engagement
- 54. ALSO.. • Extreme force on the burr and burr shaft may also result in shaft fracture
- 55. PARALLEL WIRE STRATEGY • Re-crossing another guide wire just beside the entrapped burr and making a crack between the burr and vessel wall by inflating a balloon catheter has been reported Hyogo M, Inoue N, Nakamura R, Tokura T, Matsuo A, Inoue K et al. Usefulness of conquest guidewire for retrieval of an entrapped rotablator burr. Catheterization and Cardiovascular Interventions. 2004;63(4):469-472
- 56. PARALLEL WIRE STRATEGY • May not be able to pass another wire if a 6F guide is being used (Rota catheter profile approx. 4.3F) • Sakura et al. demonstrated a novel idea to remove the drive shaft sheath after cut off the system near the advancer • The rotablator system can be cut off (disassembled) distal to the advancer (including sheath, driveshaft and Rotawire)
- 57. DUAL CATHETER STRATEGY • Or can use another vascular access and guide to introduce second wire and balloon after disengaging first guide
- 58. SNARE STRATEGY • Use of a snare advance over the drive shaft of a disassembled Rota catheter (similar to previous technique) • Allows application of local traction just proximal to the lesion • Requires 7F guide • Method is inspired by pacemaker lead extraction techniques Prasan A, Patel M, Pitney M, Jepson N. Disassembly of a rotablator: Getting out of a trap. Catheterization and Cardiovascular Interventions. 2003;59(4):463-465
- 59. MOTHER-IN-CHILD TECHNIQUE • Deep intubation with subsequent pullback of all devices can be useful to focus the force on the burr and to protect the rest of the coronary artery • Once again this can be facilitated by cutting off the system and introducing a second smaller guiding or extension catheter over the drive shaft • By simultaneous traction on the burr shaft and counter-traction on the child catheter, the catheter tip can act as a wedge between the burr and the surrounding plaque, which may exert a larger and more direct pulling force to retrieve the burr Kimura M, Shiraishi J, Kohno Y. Successful retrieval of an entrapped rotablator burr using 5 Fr guiding catheter. Catheterization and Cardiovascular Interventions 2011;78(4):558-564
- 60. LAST RESORT • An emergent open surgery would be the most reliable and always the last option for removing the entrapped burr • But Invasive Time-consuming Not immediately possible in hemodynamically unstable patients
- 61. STUCK ABLATOR • Interventional cardiologists using rotablator should be familiar with these tips and tricks to avoid and rescue this complication Sulimov D, Abdel-Wahab M, Toelg R, Kassner G, Geist V, Richardt G. Stuck rotablator: the nightmare of rotational atherectomy. EuroIntervention. 2013;9(2):251-258.
- 62. SLOW FLOW/ NO RE-FLOW
- 63. ADVANCER STOPS • Check all connections • Check air source – make sure it is on & delivering 90-110 PSI • Likely a lack of saline allowed “burn out”, which happens quickly • New advancer needed if no saline drip through advancer
- 64. STALL LIGHT LIGHTS UP • As a safety feature, the system automatically stalls whenthere is a > 15,000 rpm drop for a ½ second or more • Ensure the burr is not lodged • Pullback and re-platform proximal to the lesion • Ensure all connections are secure (air supply, saline)
- 65. PERFORATION • Stent-graft implantation OR • Emergency Surgery
- 67. CURRENT STATUS • Rotablation now plays a role as a tool to make PCI possible in de-novo complex lesions with moderate or severe calcification when clinical variables make PCI appropriate
- 68. CURRENT STATUS • For patients with ISR, Rotablation is reserved as a second choice in select cases • Rotablation may be useful when a lesion cannot be crossed with a balloon, or when multiple jailed side branches exist, using plaque debulking to minimize “snow plow” plaque displacement with balloon dilation In cases where metallic stent struts contribute directly to luminal obstruction, rotablation may be utilized for stent ablation • Otherwise, non-RA strategies, such as high pressure balloon, drug-coated balloon, or cutting balloon dilation, are preferred, especially for cases of stent under expansion
- 70. CONCLUSION
- 71. CONCLUSION • Rotablation remains an integral tool to permit optimal angiographic outcomes in treatment of complex coronary disease involving moderately to severely calcified lesions • However evidence has yet to demonstrate that routine RA before DES reduces restenosis • It is possible that the impact of RA on repeat revascularization is most pronounced for a subset of heavily calcified lesions • IVUS or OCT is useful in identifying features of plaque morphology predictive of benefit
- 72. CONCLUSION • Experience is of utmost importance – outcomes are directly related to operator experience • Complications may be dreadful and careful selection of patients is a must • Interventionists should be prepared for complications and remain vigilant