The document discusses the use of rotablation in calcified coronary lesions. It notes that calcium is common, found in 12-26% of PCI cases, and can prevent optimal stent expansion. Rotablation is an important tool for preparing calcified lesions to facilitate stent delivery and expansion. It describes a case of a 65 year old male with unstable angina undergoing CTO PCI of a heavily calcified lesion. Attempts to cross the CTO with balloons and wires were unsuccessful. After rotablation with a 1.25mm burr, dissection occurred but stents could be delivered. The conclusion is that rotablation is very useful for calcified CTO lesions to improve chances of successful stenting.

1. RCA CTO with rotablation
Andrzej Ochała
Medical University of Silesia in Katowice

2. Non-CTO Specific Tools
(but used much more commonly in CTO PCI)
• Guideliner
• Snares
• Laser
• Perforation gear
• Rotablator

3. Clinical Application: Rotablator in Calcification
Calcium is Common
The prevalence of severe calcium, defined as superficial in nature with greater than 180° arc.
Angio assessed 12% of PCI cases
IVUS assessed 26% of cases.1
Calcium can preclude optimal stenting.
Asymmetrical stent expansion occurs in up to 50% of cases where calcium is not treated before stent
deployment.2
DES, rotational atherectomy is an important tool for calcified lesions
Lesion preparation with compliance change for a calcified lesion can substantially facilitate stent delivery and
symmetrical stent expansion for more homogeneous drug delivery.3
1. Mintz et al. Patterns of Calcification in Coronary Artery Disease. Circulation April 1995, Volume 91, No 7
2. Moussa, Moses, Columbo et al. Coronary Stenting After Rotational Atherectomy in Calcified and Complex Lesions. Circulation 1997; 96:128-136
3. Iakovou, I. et. al. J Am Coll Cardiol 2005;46:1446-55

4. • Probably Should
• Definitely Should
• Definitely Should Have
– “I wish I wouldn’t have done that” category
Rotablator

5. Rotablator Indications
Should
•
•
•
•
•
Calcification
Diffuse disease
Bifurcation Debulking
CTO- Deliver gear
Lesion Preparation
Should Have
• Goal is to not operate in
this space.

6. Prior to use, please see the complete ‘Directions For Use’ for more information on Indications, Contraindications, Warnings, Precautions, Adverse Events and Operator’s Instructions.
Rotablation : Precautions, Contraindications
Precautions
• Ejection fraction less than 30%
• Lesions longer than 25mm
• Angulated lesions
• Recommend temporary pacemaker in the RCA and dominant Cx
• Rotablator System use should only be carried out at hospitals where
emergency bypass surgery can be immediately performed in the event
of a potentially injurious or life threatening complication.
Contraindications
• Saphenous Vein Grafts
• Last Remaining Vessel
• Thrombus
• Significant Dissection
• Non-surgical candidates

7. Rotational Atherectomy Complications
Eftychiou et al TCT 2014
N= 518

8. Console DynaGlide™ foot pedal
Hardware

9. Rotawire™ Floppy Guide Wire
• Flexible and torqueable to enhance navigation
• Significantly reduced guidewire bias
• Short Spring Tip (2.2 cm)
• Light rail support
330 cm total length

10. Rotawire™ Extra Support Guide Wire
• Spring Tip (2.6 cm)
• Lead wire for those physicians requiring a “stiffer” wire
330 cm total length

11. • 65 years old male
• Unstable angina CCS III
• Hypertension
• Hyperlipidemia
• Diabetes Mellitus
Case presentation

12. Laboratory results:
• Hb=11.90 g/dl, L=3.54 103/ul, E=3.91 106/ul, Ht=34.90%
• Creatinine = 0.79 md/dl, GFR>60ml/min/1.73m2
• TCH=149 mg/dl; LDL=88 mg/dl; HDL=35 mg/dl; TG=129 mg/dl
Case presentation

13. Electrocardiogram:
• LVEF=50%, hypokinesia inferior wall.
• Atrial fibrilation, HR 70-80/min.
Medications:
• aspirin, clopidogrel, bisoprolol, digoxine, perindopril, VKA, rosuvastatin,
pantoprazole.
Case presentation
Echocardiography:

14. Basal Angiography (bilateral injection)
Dual arterial access with EBU 7Fr left femoral and JR4 8Fr right femoral

15. CTO ballon NC nano 0.85x10mm failed to cross CTO
Wire - ASAHI Filder XT-A
Procedure
Predilatation of proximal segment
Ballon Apex 3.0x20mm

16. Procedure
Guideliner 6Fr
Corsair (unsucceful corssing)
Change wire for rotawire

17. Procedure
Dissection type E after rotablation
(1.25mm burr size)

18. Contrast volume = 250 ml
DES Synergy (Everolimus) 2.5x24mm
DES Synergy (Everolimus) 3.0x32mm
DES Synergy (Everolimus) 3.5x32mm
DES Resolute (Zotarolimus) 3.5x18mm
Final result

19. Conclusions
• Many CTO cases are done today in highly calcified lesions.
• Succesful passage with guide wire in CTO in not the success of
procedure.
• Rotablation is very useful in calcified CTO lesions cases.
• Rotablation in CTO cases will definitely increased in numbers in the
nearest future.