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Navin`s rota ppt


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tips and tricks of rotaablation

Navin`s rota ppt

  1. 1. Rota ablation
  2. 2. Atherectomy: Rotablator® Diamond microchips Differential cutting PTCA Rotablator®; Boston Scientific, Inc., Natick, Mass. PRCA
  3. 3. ROTA (Invented BY David Auth 1980 1st used for angioplasty by Reisman et al 1996) Indications: • • • • • • • Calcified lesion Undilatable/chronic lesion Diffuse long lesion In-stent restenosis Bifurcation lesion Ostial lesion ? Small vessels (< 2.5 mm)(Mauri et al 2003) Limitations: • • • • • • Slow flow / No flow Perforation CK-MB release Spasm and dissection Technically challenging Heat generation
  4. 4. CONTRAINDICATIONS • Acute myocardial infarction • Thrombus containing lesion • Saphaneous Vein Grafts • Dissection • Lesions at bend/tortuous vessels • Extremely eccentric lesions
  6. 6. TIPS AND TRICKS FOR ROTA ABLATION It is essential to use specific guiding catheters with sufficient support and coaxial fitting. TPI should be ready in case of RCA lesion Slow burr advancement To-and-fro pecking motion of the burr Shorter burr run times (15–20 sec) Lesion contact time of 1-3 seconds with longer 3-5 seconds of reperfusion to allow debri clearance 30 seconds of burr rotation to be followed by 30 seconds of rest Contrast injection during every rest interval
  7. 7. TIPS AND TRICKS CONTD…. 1. Low burr speeds (140,000–150,000 RPM) 2. Strict avoidance of significant drops in rpm (> 5000 RPM for > 5 sec) 3. Flush the system with diluted contrast (1:10 dye-to-saline ratio) during the ablation runs. 4. Keep systolic blood pressure > 100 mm Hg during the procedure 5. Keep the guidewire wet at all times to avoid friction (Brown et al, 1997; Reifart et al, 1997; Whitlow et al, 2001; Dill et al,2000; Buchbinder et al, 2001; vom Dahl J et al, 2002; Goldberg et al, 2000) :
  8. 8. 1. GP IIB/IIIA infusion to be used in all cases unless contraindicated 2. Significant underestimation of vessel size can occur in the first 24 hours after rot ablation(Reisman et al) 3. IVUS use to guide therapy is recommended. Lesions with superficial calcification are more suitable than those with deep calcification(IVUS crossing the lesion is not possible in most cases) 4. Single burr debulking strategy is favored over multi burr strategy (STRATAS Trial) 5. Burr To artery Ratio(<0.75)(STRATAS TRIAL) 6. Preferable to use DES (Moses et al 2003,Stone et al 2004,Khattab et al 2007, Benezet et al 2011.Pagnotta et al 2010,Mezilis et al 2010)
  9. 9. • During RotA, 500 ml of heparinised (5000 units) normal saline solution with 5 mg verapamil and 1000 μg nitroglycerine is administered locally, with a view to preventing thrombus formation and vascular spasm, and avoiding the no-reflow phenomenon. • Ensure that the rotawire has no loops or kinks • Change in the pitch of turbine noise may suggest resistance or friction to burr. • Avoid vasodilators during procedure to minimize hypotension risk. • In bifurcation lesions Rotablation should be started at the most difficult to wire branch first. Use low burr-artery ratios (<0.5) especially when there is angulation present. • In tortouus vessels Keeping the tip of the guidewire just beyond the lesion is essential in order to reduce sidewall tension. Use undersized burr. (Brown et al, 1997; Reifart et al, 1997; Whitlow et al, 2001; Dill et al,2000; Buchbinder et al, 2001; vom Dahl J et al, 2002; Goldberg et al, 2000):
  10. 10. ROTATIONAL ATHERECTOMY AND PLATELETS Activation of Platelets by Rotablation Is Speed-Dependent Transmission electron micrography: • Platelet-rich plasma through chamber with rota burr held stationary (0 rpm) and stirred in an aggregometer for 5 minutes: Intact platelet membrane, intracellular granules, and clear background. • Platelet-rich plasma was subjected to rotablation at 180,000 rpm and stirred in an aggregometer for 5 minutes: Ruptured platelet membranes, depletion of intracellular organelles (“ghost platelets”), From Williams MS. Circulation. 1998;98:742-748. and cloudy background.
  11. 11. Rotational Atherectomy and Platelets Initial Aggregation Slope (units/min) Effect of Rotablation on Platelet Aggregation Rotablation Speed (rpm x 10-3) From Williams MS, et al. Circulation. 1998;98:742-748.
  12. 12. Porcine blood exposed to a rotating burr resulted in: Platelet aggregation and red blood cell crenation. From Reisman M, et al. Cathet Cardiovasc Diagn. 1998;45:208-214.
  13. 13. STRATAS Trial (500 PTS RANDOMIZED TRIAL) Technique Matters: Incidence of Slow-Flow • Predictors of CK-MB release: – deceleration > 5000 rpm > 5 sec P = .008 % • Predictors of restenosis: – deceleration > 5000 rpm – LAD location – Multiburr strategy Aggressiv e strategy Routine strategy (n = 249) BA: > 0.9 (n = 248) BA: < 0.8 Whitlow PL, et al. Am J Cardiol. 2001;87:699-705. Current optimal Burr-toArtery Ratio (BA): 0.3-0.5
  14. 14. Rotational Atherectomy: Complications Slow-flow Settings: • • • • • Long calcified lesions Total occlusion and right coronary artery Poor LV function and hemodynamic instability Thrombotic lesions (also post-MI) ? on -blockers Technical modifications: • • • • • Small initial burr size and small upsizing Short ablation runs and avoid RPM drops ?Slow-speed Avoid hypotension and bradycardia Rota flush & GP IIb/IIIa inhibitors Treatment: verapamil, nitro, adenosine, nitroprusside, IABP
  15. 15. MECHANISM OF NO/SLOW-FLOW • • • • • • • • • • Atheromatous debris embolism Platelet and microthrombi Platelet activation, aggregation, lysis (by rota burr) Microcirculatory (vasculature) spasm Heightened microvasculature reactivity / tone Microcavitation Impaired local synthesis of EDRF Neuro-humoral reflex Lower epicardial vessel pressure and higher LVEDP Extreme cases: free radical injury, local edema, microvascular plugging, no-reflow
  16. 16. Rotational Atherectomy: Complications Perforation Settings: • • • • Lesion in a bend > 90 Calcified lesion Large burr-to-artery ratio Total occlusion Technical modifications: • • • • • Smaller initial burr size (start with 1.25 mm burr) Bending the wire technique Rota extra support wire ?Predilatation with a smaller balloon Avoid abciximab before rotablation
  17. 17. Rotational Atherectomy Mount Sinai Hospital Experience (6%-9% of PCI) % Complications ---DES--- short burr runs, rota-flush, abciximab, stent, experience slow speed (140-150,000 rpm) rotational atherectomy, BA: 0.4-0.5
  18. 18. Rota+BMS vs Rota+DES Procedural and Clinical Results Rota + BMS (n = 284) Rota + DES (n = 130) P = NS P = NS P < .01 P = .62 P = .09 % % P = NS Procedural Success Clinical Success CK-MB >3x 30-day Stent TVR MACE Thrombosis MACE = major adverse cardiac events; TVR = target vessel revascularization Data presented by Sharma S, et al. American College of Cardiology Scientific Sessions, Chicago, Ill, 2008
  20. 20. THANK YOU