Successful rotational atherectomies for calcified left main stenosis with distal aneurysms in the elderly

In complex calcified LM lesions, RA is an effective and safe alternative for resolving stenosis. As a plaque modifier, RA can allow an optimal stent deployment. Nevertheless, in limited availability of intravascular imaging, well‐preparedness against incidental angiography findings is mandatory. Distal aneurysm is not a contraindication provided that the team has the necessary experience.     

Coronary intravascular lithotripsy and rotational atherectomy for severely calcified stenosis: Results from the ROTA.shock trial

Background

Severely calcified coronary lesions present a particular challenge for percutaneous coronary intervention.

Aims

The aim of this randomized study was to determine whether coronary intravascular lithotripsy (IVL) is non-inferior to rotational atherectomy (RA) regarding minimal stent area (MSA).

Methods

The randomized, prospective non-inferiority ROTA.shock trial enrolled 70 patients between July 2019 and November 2021. Patients were randomly (1:1) assigned to undergo either IVL or RA before percutaneous coronary intervention of severely calcified coronary lesions. Optical coherence tomography was performed at the end of the procedure for primary endpoint analysis.

Results

The primary endpoint MSA was lower but non-inferior after IVL (mean: 6.10 mm², 95% confidence interval [95% CI]: 5.32–6.87 mm²) versus RA (6.60 mm², 95% CI: 5.66–7.54 mm²; difference in MSA: −0.50 mm², 95% CI: −1.52–0.52 mm²; non-inferiority margin: −1.60 mm²). Stent expansion was similar (RA: 0.83 ± 0.10 vs. IVL: 0.82 ± 0.11; p = 0.79). There were no significant differences regarding contrast media consumption (RA: 183.1 ± 68.8 vs. IVL: 163.3 ± 55.0 mL; p = 0.47), radiation dose (RA: 7269 ± 11288 vs. IVL: 5010 ± 4140 cGy cm²; p = 0.68), and procedure time (RA: 79.5 ± 34.5 vs. IVL: 66.0 ± 19.4 min; p = 0.18).

Conclusion

IVL is non-inferior regarding MSA and results in a similar stent expansion in a random comparison with RA. Procedure time, contrast volume, and dose-area product do not differ significantly.     

An algorithmic approach to balloon undilatable coronary lesions

Balloon undilatable lesions are lesions that have been successfully crossed by both a guidewire and a balloon but cannot be expanded despite multiple high-pressure balloon inflations. Balloon undilatable lesions can be de novo or in-stent. We describe a systematic, algorithmic approach to treat both de novo and in-stent balloon undilatable lesions using various techniques, such as high-pressure balloon inflation, plaque modification balloons, intravascular lithotripsy, very high-pressure balloon inflation, coronary atherectomy, laser coronary angioplasty, and extraplaque lesion crossing. Knowledge of the various techniques can increase the efficiency, success and safety of the procedure.     

A novel model to evaluate the fatigue resistance of NiTi instruments: Rotational and axial movement at body temperature

To develop a model to test cyclic fatigue resistance of TruNatomy instruments undergoing rotational and axial movement at body temperature. A total of 288 Prime and Medium instruments were subjected to cyclic fatigue testing in simulated canals (at 37°C) using a model with either rotational movement only or rotational and axial movement simultaneously. Two different sized canals and three different types of curvatures were tested for each instrument (30/0.04 and 30/0.06 for Prime; 38/0.04 and 40/0.06 for Medium). The number of cycles to failure (fatigue resistance) was recorded. Rotational and axial movement of instruments led to greater fatigue resistance compared with rotational movement alone. Apical curvatures led to greater fatigue resistance than curvatures in the coronal and middle third. The developed dynamic model at body temperature to evaluate fatigue resistance of instrument closer simulates clinical scenarios.     

Mean density of computed tomography for predicting rotational atherectomy during percutaneous coronary intervention

BackgroundMulti-slice computed tomography (CT) allows noninvasive evaluation of the severity of coronary calcification. However, there has yet to be a definitive parameter based on the cross-sectional CT image for predicting the need for rotational atherectomy (RA). Therefore, we aimed to investigate the mean density of cross-sectional CT images to predict the need for RA during percutaneous coronary intervention (PCI).MethodsA total of 154 lesions with moderate to severe calcification detected in coronary angiography were identified in 126 patients who underwent coronary CT prior to PCI for stable angina. PCI with RA was performed for 48 lesions, and the remaining 106 were treated without RA. Multi-slice CT was retrospectively evaluated for its ability to predict the use of RA. We chose the most severely calcified cross-sectional image for each lesion. The mean density within the outer vessel contour, calcium arc quadrant of the cross-sectional CT image, calcium length, calcification remodeling index, and per-lesion coronary artery calcium score was studied.ResultsReceiver-operator characteristic curve analysis revealed 637 Hounsfield units (HU) (area under the curve ​= ​0.98, 95% confidence interval: 0.97–1.00, p ​< ​0.001) as the best mean density cutoff value for predicting RA. Multivariate logistic regression analysis showed that a mean calcium level >637 HU was a strong independent predictor (odds ratio: 32.8, 95% confidence interval: 7.0–153, p ​< ​0.001) for using RA.ConclusionsThe mean density of the cross-sectional CT image, a simple quantitative parameter, was the strongest predictor of the need for RA during PCI.