A review of Rotablation technology, its application, and usage in the catheterization laboratory. Ideal for Interventional Cardiology Fellows.

1. ROTABLATION
– A REVIEW

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)

14. INDICATIONS
AND
CONTRAINDICATIONS

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)

19. EQUIPMENT AND SET-UP

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

66. CURRENT STATUS OF
ROTABLATION

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

73. Thanks for listening….