Rotational Atherectomy: Complex Cases and Complications A/Prof Yeo Khung Keong MBBS, ABIM (Internal Medicine, Cardiology, Interventional Cardiology), ABVM (Vascular Medicine, Endovascular), FAMS, FACC, FSCAI Senior Consultant, Cardiology National Heart Centre Singapore Adjunct Associate Professor Duke-NUS Graduate Medical School 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 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 Relative Contraindications to Rotablator • Impaired left ventricular function - Combination of low LVEF and blood pressure • Intracoronary thrombus • Coronary dissection • Saphenous vein grafts ‘No-reflow’ • A feared and common complication • Microcirculatory debris • Platelet activation (excessive speeds) • Coronary vasospasm • 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 Complications • Perforation • Oversize burrs • Guide wire bias • Tortuosity • Dissection • Tamponade from pacing wire • Stuck burr 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 wire • Stuck burr 10 LCA Final Angio 77 LCA Final Angio 78 Complication 79 80 81 82 83 84 85 86 8 Summary • Rotational atherectomy crucial to complex PCI • Preparation, practice and anticipation • Complications can be dangerous but fortunately, uncommon • Good technique critical to avoid complications – Start small – ‘Sandpaper technique’ – Speed at 150,000 rpm