Rotational Atherectomy

• Utilizes a high speed (160,000+ RPM) rotating diamond coated burr to ablate atherosclerotic plaque and restore luminal patency.
• Unlike orbital atherectomy, Rota burr diamonds are present in the front half of the burr; therefore the atherectomy is done with small pecking and forward motions only.

Principles of rotational atherectomy

• Differential cutting
  • All diseased plaque is inelastic
  • High speed rotational ablation differentiates healthy elastic vessel wall from plaque
• Orthogonal displacement of friction
  • Friction develops in longitudinal direction between the guide wire and the device
  • High speed rotation changes the friction vector to a circumferential direction

Common uses

• Severely calcified lesion
• Undilatable/chronic lesion
• Diffuse long lesion
• Small vessels (< 2.5 mm)
• In-stent restenosis
• Bifurcation lesion
• Ostial lesion

Contraindications

• Thrombotic lesions
• Extremely tortuous lesions

Procedural steps

• Select proper burr size (0.5-0.6:1 burr to artery ratio)
• Select Proper guide size (1.25-1.75 burr = Use 6Fr, 2.0 burr = Use 7Fr, > 2.0 burr = Use 8Fr)
• NC balloon (1:1) prepped and ready
• Temporary pacemaker for RCA or dominant LCx/unprotected LM lesions
• Be gentle when removing the RotaWire from packing, wipe and make 3 large loops
• Assess if the lesion can be directly wired with RotaWire (70-80% stenotic calcified lesion)
• If cannot be directly wired ( > 90% stenosis, long lesions, tortuous lesions)
  • Wire using Over-the-wire (OTW) technique using micro catheter (such as fine cross TM, Terumo, Tokyo, JP) or OTW balloon
  • Once the lesion is crossed with fielder or workhorse wire, advance the microcatheter or OTW balloon pass the lesion
  • Remove the wire (make sure to flush with 5cc of saline while removing the wire to prevent air entry)
  • Advance the RotaWire through the microcatheter or OTW balloon past the lesion
  • Slowly remove the microcatheter or OTW balloon with maintaining the wire position
  • If unable to advance the microcatheter or OTW balloon past the lesion, advance up to the lesion, remove the wire and advance the RotaWire and try to directly wire the lesion
  • If unable to advance the RotaWire past the lesion, remove the wire and reinsert the workhorse wire and perform atherectomy with Excimer laser
  • If RotaWire crosses the lesion but the microcatheter or OTW balloon doesn’t cross the lesion, downgrade the burr to 1.25mm
• Make sure the clip is attached to the back end of the wire before you advance Rota catheter through the guide that needs to be attached through the atherectomy, only to be removed after the Rota catheter is removed from the guide.
• Perform a speed check (140K-150K RPM) before advancing the Rota catheter
• Rota flush needs to be continuously flushed throughout the procedure
• Technique:
  • Slow burr advancement
  • To-and-fro short pecking motions of the burr
  • Shorter burr runs (15-20 secs)
  • Low burr speeds (140-150K rpm)
  • Strict avoidance of significant drop in rpm ( > 5K rpm for 5 sec)
  • Keep SBP > 100mmHg, if needed give 100-200mcg Neosynephrine
  • Advance on dynaglide mode and move forward for distal lesions
• After atherectomy is done and Rota catheter is out of the guide with dynaglide on, turn off the flush and remove the clip (Remember clip off and drip off). Make sure wire does not come out.
• Take cine to rule out complications.
• Once the atherectomy is done, try to wire side-by-side with workhorse wire.
• If unable to wire side-by-side, advance microcatheter or OTW balloon over the RotaWire and then exchange with 300cm workhouse wire, which can be used for angioplasty and stenting.

First generation device: ROTABLATOR™(Boston Scientific, Natick, MA)

Advancer

Second generation device: ROTAPRO™(Boston Scientific, Natick, MA)

Rota flush

• Ingredients
  • Rotaglide solution one vial + 5000mcg of nitroglycerin + 5mg of verapamil + 5000 units of heparin mixed in one liter normal saline bag. Avoid nitroglycerin in Aortic stenosis patients.
  • ROTAGLIDE is a lipid based emulsion designed to lubricate the ROTABLATOR/ROTAPRO system.
  • ROTAGLIDE
    • Reduces friction and improves tactile feel
    • Reduces heat build-up around the ROTABLATOR burr
    • Reduces sudden drops in RPMs caused by lesion feedback
    • Is contraindicated if patient is allergic to eggs or olive oil