Rotational Atherectomy, Cutting Balloons, Angiosculpt & Lacrosse • A/Prof Yeo Khung Keong • MBBS, ABIM (Internal Medicine, Cardiology, Interventional Cardiology), ABVM (Vascular Medicine, Endovascular), FAMS, FACC, FSCAI • Senior Consultant, Cardiology Heart Centre Singapore Adjunct Associate Professor Duke-NUS Graduate Medical School • National Disclosures • Abbott Vascular: Speaker and Proctor (MitraClip) • Medtronic: Research grant When? • Think about lesion, patient, scenario, device, bail-out options – STEMI? – Calcified lesion? ISR? – BVS? • Lesion preparation – ISR and Calcified lesions – BVS, difficult stents, tortuous vessels High Speed Rotational Atherectomy - Rotablator • Invented by David Auth Ph.D in 1988 • Elliptical Burr covered with Diamond Particles - protrudes < micron • Burr rotated at 140,000 to 180,000 RPM • Atherosclerotic plaque is ablated - “Differential Cutting” • Preferentially and selectively ablates inelastic tissue while sparing elastic tissue • Particle size is < micron (RBC ~ micron) • Dispersed in coronary circulation • Cleared by Reticulo-Endothelial System in Liver, Spleen & Lung • Primary use is plaque modification and debulking of calcified plaque • Most useful for superficial calcium greater than 180o Under-expanded lesions • Unable to deliver stents • When stents deployed: under-expanded – risk of stent thrombosis very high Rotablator • High speed rotational atherectomy is absolutely essential for complex coronary interventions Rotablator System • • • • Console Foot Pedal Advancer Burr - Wire channel 0.010” • Sizes: 1.25, 1.5, 1.75, 2.0, 2.15, 2.25, 2.5 mm • Guide Wire - 0.009” tip 0.007” • Flex • Extra-support • Compressed Gas (Air or Nitrogen)- 90 to 110 PSI • Saline Flush - Rotaglide Console Stall Light Dynaglide Light Procedure Timer Reset Button Rotational Speed Display (Tachyometer) Turbine Pressure Control Gauge Turbine Pressure Control Knob (Adjusts RPM) Event Timer Power Switch Advancer Fiber Optic Connector Dynaglide Connector Turbine Connector Power Light 10 Cutting balloon • • • • • • Bulky Hard to deliver Aid in plaque modification so that stents can be well expanded Inflate slowly Deflate slowly Cannot have second wire: wire fracture 35 FlextomeTM Cutting BalloonTM Device Components Non-compliant Balloon – Nylon material – Predictable & consistent dilatation – Secure fixation of flexible atherotomes • Diameter: - 4mm in 0.25mm increments • Length: 6, 10, 15mm • Pressure: nominal atm/608kPa; RBP 12 atm/1216kPa 36 Cutting BalloonTM Device Mechanism of Action - Summary Feature Mechanism of Action 3-4 atherotomes Scores the plaque1,2,5,6,7 Severs the elastic and fibrotic continuity of the vessel wall1 May help to prevent balloon slippage9 (microsurgical blades) mounted longitudinally along a noncompliant balloon Non-Compliant Nylon Balloon material Dilates the target lesion at lower pressures2,4,5 Lumen gain achieved primarily through plaque compression and less to vessel wall expansion2,7,8 Bonan, J Invasiv Cardiol, 1999; 11: 230 Hara et al., Am J Cardiol 2002; 89:1253-1256 Ergene et al, J Invas Cardiol 1998; 10: 70-75 Global Randomized Trial - Cutting Balloon Device Directions for Use; Data on File Inoue et al., Circulation, 1998; 97:2511-2518 (US SCI #2392) Yamaguchi et al., J Interven Cardiol 1998; 11(Suppl) S114-S119 Suzuki et al., Amer J Cardiol 1999; 84 Suppl:58P (US SCI #2525) Taniuchi, et al The WINNER Registry Catheter Cardiovasc Interv 2004;62:C–36 Inflation & Deflation Technique* • Slow inflation—dial up atm(101.3kPa)/5-sec • Slow deflation—dial down atm(101.3kPa)/5-sec then pull negative for optimal balloon rewrap • Repeat angiography • Multiple inflations can be performed NOTE: Do not torque the catheter between inflations Important: Choose shorter lengths for easier access 38 Angiosculpt • • • • Similar function to cutting balloon But easier to deliver May have additional wire (eg bifurcations or buddy) May have role in bifurcations (?) 39 AngioSculpt Mechanism of Action TheEdges AngioSculpt Scoring Balloon “lock” in • A laser-cut, helical, nitinol scoring element • Mounted on a low-profile, semi-compliant balloon Scoring Element strut height 0.005” ©AngioScore 2007 Do Not Copy or Distribute For Educational Use Only ML-1040-0001 Rev A 4/07 IVUS Pre-Dilatation Study (Costa) • Non-randomized, observational study using IVUS to compare DES expansion after pre-dilatation strategies I Direct stenting without pre-dilatation (n=145) II Pre-dilatation with a conventional semi-compliant balloon (n=117) III Pre-dilatation with the AngioSculpt Scoring Balloon Catheter (n=37) • N=299 de novo lesions, all treated with a DES ≥ 2.5 mm • Baseline patient and lesion characteristics well matched Costa JR, Mintz GS, Carlier SG et al Nonrandomized Comparison of Coronary Stenting2007 Under Guidance of Direct Stenting Without Predilation Versus ©AngioScore DoIVUS Not Copy or Distribute For Educational Use Only ML-1040-0001 Conventional Predilation With a Semi-Compliant Balloon Versus Predilation With Rev A 4/07 a New Scoring Balloon Am J Cardiol, 2007; 100:812-817 Acute Gain (mm) 50% gain 1.5 33% gain Acute Gain (mm) 1.2 0.9 0.8 + 0.4 1.2 + 0.4 0.9 + 0.6 p =0.004 0.6 0.3 0.0 Direct Stent POBA AngioSculpt • p = 0.004 applies to the comparison between Direct Stent vs AngioSculpt • comparison between Direct Stent vs Pre-dil with POBA shows no statistical difference Costa JR, Mintz GS, Carlier SG et al Nonrandomized Comparison of Coronary Stenting Under ©AngioScore 2007.ofDo Not Copy or Distribute For Educational UseConventional Only ML-1040-0001 IVUS Guidance Direct Stenting Without Predilation Versus Predilation With a SemiRev A 4/07 Balloon Versus Predilation With a New Scoring Balloon Am J Cardiol, 2007; 100:812Compliant 817 % of Predicted Stent Diameter* Reached 100 93 85 78 70 63 55 48 40 33 25 18 10 p 5.0mm2 % of Stents with Final Luminal Area ≥ 5.0 mm² 113% 90% 89% 74% 74% p [...]... pericardiocentesis, covered stents • Covered stents: Graftmaster Jostent, Bestent, • Guide size • Rehearse steps going in and coming out • Defibrillator on standby 16 Preparation • Get intracoronary vasodilators ready: pretreat before root a good idea • Verapamil 100mcg, adenosine 100mcg, nitroprusside 1020mcg, GTN 100mcg • Appropriate anti-platelet therapy • pre-loaded with DAPT vs GP IIB/IIIA 17 Technique... 12 Relative Contraindications to Rotablator • Impaired left ventricular function - Combination of low LVEF and blood pressure • Intracoronary thrombus • Coronary dissection • Saphenous vein grafts 13 Philosophy • Is it easier to prevent than to treat • It is easier to prepare the lesion than struggle later 14 Differential Cutting Elastic Tissue Inelastic Tissue Rotary Sander 15 Preparation • IABP if... • Important to have pre-treat with anti-platelets • Avoid excessive roto speeds • Intracoronary verapamil/nitroprusside/adenosine/GTN via microcatheter, or OTW wire (inflated) or dual lumen catheters/aspiration catheters • IABP 21 Tips and Tricks • Heart Block • Avoid high RPM > 150,000 • Use good technique • Temporary pacemaker • Aminophylline pretreatment - 250 mg IV over 20 min • For long lesions,... burr through hemostatic valve while simultaneously moving the advancer back to regain more travel 22 Tips and Tricks • ‘Sandpaper’ vs ‘Woodpecker’ techniques • ‘Sandpaper’: 3 seconds gentle pressure then 2 seconds withdraw to allow perfusion/flush • RPMs: 150,000/min vs >160-180,000/min • Allow rest, check contrast injections • Check ECG, patient symptoms, BP • ‘Polish’ 23 24 Tips and Tricks • OK to... clear, Slow Flow or No Flow 1 Tips and Tricks • Technically Challenging • Unfriendly guidewire • Use 2.0 over the wire balloon and favorite wire • Exchange for Rotawire • Extra support vs floppy - no big difference • Limited clearance between burr channel and wire - 0.001” • Orthogonal Displacement of Friction • Use Dynaglide to advance burr • Add RotaGlide to saline flush 20 ‘No-reflow’ • A feared... OK to go >30 second • Be familiar with the wire: I use roto-extra support almost all the time • Sizing 25 Some Tips • If you think about it, you probably should do it • If you don’t use it enough, you won’t know how to do it when you need to use it • If you haven’t seen a complication, your next one could just be it 26 Complications • Perforation • Oversize burrs • Guide wire bias • Tortuosity • Dissection... complication, your next one could just be it 26 Complications • Perforation • Oversize burrs • Guide wire bias • Tortuosity • Dissection • Tamponade from pacing wire • Stuck burr 27 Complications • Perforation • Leave wire in place • Exchange for regular wire • Reverse anticoagulation • Long balloon inflation • Covered stent • Coil • Check echo for pericardial effusion • Dissection • Tamponade from pacing... 30 Basic Case 31 32 33 34 Cutting balloon • • • • • • Bulky Hard to deliver Aid in plaque modification so that stents can be well expanded Inflate slowly Deflate slowly Cannot have second wire: wire fracture 35 FlextomeTM Cutting BalloonTM Device Components Non-compliant Balloon – Nylon material – Predictable & consistent dilatation – Secure fixation of flexible atherotomes • Diameter: 2 - 4mm in 0.25mm