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Rotational atherectomy (RA) is an effective tool to prepare calcified lesions prior to stent implantation. We assessed the incidence and reasons of complications during RA. It may be useful to prevent future complications.
From 10828 consecutive patients with PCIs, 343 patients (3.2%) underwent RA (353 vessels) in severely calcified lesion with failed balloon dilation. Procedural success (defined as RA plus stent with residual stenosis <20% and TIMI ≥ II without severe complications, defined as death, Q-wave myocardial infarction, perforation of RV or vessel and urgent CABG.) was achieved in 343 vessels (97.2%).
Mean age 70.2 ± 8.2 yrs, 84% male. Patients demographics and procedural data were not different between patients with successful vs. non successful procedures. Severe complications occurred in 7 pts (2%): 3 patients died (0.9%), 4 pts. (1.2%) underwent emergency surgery. This analysis focuses on those 5 patients, whose complications were related or caused by RA. Pt. 1 (death) died from cardiogenic shock when RA was performed on LAD despite presence of severe aortic stenosis and hypokinesia of the inferior wall. Here TAVI should have been performed before RA to avoid severe hemodynamic compromise. Pt 2 (death) also developed cardiogenic shock after successful CX-RA in presence of a significant LAD-stenosis, not identified as the target vessel. In Pt. 3 (surgery) rotawire fractured and burr got trapped due to too brisk advancement of the rotablator in a severe vessel tortuosity. In this case rules of using the burr (gentle, slow, RA < 20 sec) were disregarded. Pt 4 (surgery) had RA of LAD/diagonal with unsuccessful wire crossing of the LAD and only RA of the diagonal, which resulted in vessel perforation. This pt should have had CABG in first place, because the main branch could not be wired. In pt. 5 (surgery) a non balloon-tipped temporary pacing lead (TPL) induced perforation of the RV. This complication was not caused by RA itself but is closely related because the use of TPL is recommended especially when RA of a dominant RCA is planned. Complications in remaining 2 pts were not related to or caused by RA: one pt. (death) developed cardiac tamponade caused by wire perforation in a non rotablated vessel, the second pt. (surgery) showed a severe calcified bifurcation with failed wire crossing.
In this large cohort of PCI patients RA was performed in 3.2%. Severe RA complications occurred in 2%. The main aspects to reduce the complication rate are: exclude patients from RA if this leads to severe hemodynamic compromise (severe aortic stenosis or wall motion abnormality on contralateral side), always respect severe vessel tortuosity and be sure vessel is securely wired, use gentle forth and back burr movement, if temporary pacing is needed (RA of dominant vessel) avoid non-balloon-tipped pacing leads. If these rules would have been followed, two out of three deaths could have been prevented and three out of four emergency surgeries could have been avoided.