Rotablation - Dr Hafeesh Fazulu - PIMS May 5th 2021

1. ROTABLATION
Dr Hafeesh Fazulu
PUSHPAGIRI CARDIOLOGY
Pushpagiri Institute of Medical Sciences
Thiruvalla, Kerala.
+91 9995706688
MANAGEMENT OF CALCIFIED LESIONS
06-05-2021

2. What will happen if you deploy stent to
heavily calcified vessel ?

3. If not prepared

4. How to manage a heavily calcified complex
lesion?
• Cutting/Scoring Balloon Angioplasty (CBA)
• Laser Angioplasty
• Atherectomy
• Directional Atherectomy
• Rotational Atherectomy - Rotablation (PTRA)

5. Very high pressure upto 32 ATM

6. SIS-OPN Balloon
• What is OPN ?

7. Chocolate Balloon

8. Cutting Balloon Angioplasty (CBA)
• NC balloon having longitudinal MICROTOMES mounted on it
• ‘controlled longitudinal incisions’
• ATHEROTOMY
• At lower pressure vs conventional balloon angioplasty

9. Scoring Balloon
• ANGIOSCULPT

10. Laser Angioplasty

11. ATHERECTOMY

12. Directional Atherectomy

14. Orbital Atherectomy

15. ROTABLATION

18. How does it look on Angio?
Rotawire - Floppy
Burr

19. Importance of Guide Cathter POSITION
Guidewire placement is important in efficiency of debulking

20. • Plaque is ablated into small particles
called microparticles
• The size of the microparticles is less
than 5 microns(smaller than a red
blood cell)
• The microparticles are picked up by
the RES (Reticulo-Endotheliel
System)

21. Mechanism
• 1. “Differential Cutting”
• Ability to selectively ablate or remove one material while sparing the second
material
• Hard fibrocalcific plaque can be ablated by a rotablator while the SOFTER
TISSUE “DEFLECTS AWAY” from the device and remains relatively unaltered.

23. Mechanism
• 2. Orthogonal Displacement of Friction
• “Perpendicular”
• Friction occurs when sliding surfaces are in contact
• But it is minimized by a sliding motion perpendicular or orthogonal to the contact
surface
• PERMITS EASY PASSAGE OF BURR thru tortous segments
• The faster something is turned, the more the friction is reduced

25. With and Without ROTA

26. Pacing maybe needed. Why?
• Rotablation can induce BRADYCARDIA
• MECHANISM
• Adenosine released by the RBC fragmentation

27. GUIDELINES on Rotablation

29. EQUIPMENT

30. Brands available
• ROTABLATOR - Boston Scientific
• ROTAPRO – Boston Scientific

31. COST
• 35 Lakhs

32. Cost for procedure ?
• 50-60k per procedure

34. Catheter and Burr

35. CONSOLE
• Controls burr rotation speed by
regulating air flow to the
advancer
• Monitors and displays burr
rotation speed and procedure
time
Fibreoptic
tachometer to
monitor
speed
RPM Monitor
Turbine
Pressure
control knob

36. Dynaglide Foot pedal
• Activates the burr by initiating the flow of air through the system
• Facilitates burr exchange or removal by switching the system in and
out of Dynaglide mode
• Reduces RPM to 60,000 to 90,000

37. Dynaglide is for removing
• NOT FOR ADVANCEMENT
• Why?
• Plastic particles maybe abraded off from the guiding catheter

38. Rotapro

39. Advancer (Rotalink) - preconnected
Secondary BRAKE

40. Rota Guidewires
• RotaWire Floppy Guide Wire
• Long, tapered shaft designed for greater
flexibility
• Designed for greater vessel straightening
in unfavorable guide wire bias situations
• RotaWire Extra Support Guide Wire
• Short, tapered shaft intended to
maximize vessel straightening to help
create favorable guide wire bias
• Added support aids in advancing the
Rotablator Burr into lesions

41. Causes damage to wire tip or burr to get stuck

42. Guidewire Bias
Keep the guidewire JUST BEYONG the lesion – not too far

43. Perforation can occur !!!

44. Burr
• Burr distal surface
• Diamond chips 20um
• 5um protruding from surface
• Burr Proximal surface (non-ablative)
• Drive shaft
• Teflon sheath

45. Burr
• Size 1.5 is usually preferred
• Larger Burr 1.75 used for
LMCA lesions
• Burr to artery ratio – 0.7
• Eg 2.15 mm burr in a 3 mm vessel

46. RPM
• Higher RPM – more platelet activation

47. Wire Clip Torquer
• While removing the Burr
• To prevent the wire from
rotating when burring

50. PROCEDURE

51. Catheter Size

54. Why? May liberate
large particles,
heating, torsional
dissection
Why? Reduces
speed drops,
aids clearance
into distal
circulation

55. Complications
• Slow flow / No Reflow
• Perforation
• Lodged burr
• Advancer stops

56. Stuck Rotablator
• May cause acute vessel occlusion
• Pull hard with the guiding catheter
• CABG Surgery

57. Limitations of Rotablation
• High cost
• Long calcified lesions – higher incidence of MI, no flow
• Bradycardia – Adenosine release by crushed RBC

58. Conclusion
• Main indication for the use of RA at present time is to alter lesion
compliance in calcified and/or undilatable lesions in order to facilitate
stent delivery and expansion and to reduce acute procedural
complications

59. THANK YOU