Rotational atherectomy for the treatment of in-stent restenosis

Restenosis after coronary stent implantation remains the major limitation of this treatment modality. At present, re-dilatation is considered the therapeutic option of choice for focal lesions, however, long restenotic lesions (>10 mm) do not respond favourably. Despite the emerging concept of intracoronary radiation, encouraging acute procedural results are also reported for different debulking techniques (Excimer laser angioplasty, directional coronary atherectomy, and rotational atherectomy, or rotablation). Rotablation has been studied most extensively with acute and long- term results published in a total of more than 850 patients. Experimental and first clinical data indicate favourable results for the rotablator as compared to balloon angioplasty alone for the treatment of in-stent restenosis. Data from the first 2 randomized clinical trials (ROSTER-, and ARTIST-trial) have now been published with conflicting results: The european multicenter ARTIST-trial including 300 patients could not prove a benefit for the rotablator as compared to re-dilatation in patients with diffuse stent restenosis. On the contrary, the monocenter ROSTER-trial, which has been presented as an abstract until today, suggests a clinical benefit of patients treated by the rotablator if they were studied with intracoronary ultrasound prior to randomization. Currently, rotablation for the treatment of restenosis cannot be considered as the first line treatment modality in patients with in-stent restenosis. As a result of unsatisfying angiographic and clinical long-term results by the use of a variety of treatment modalities in diffuse stent restenosis, prevention of this iatrogenic entity has become mandatory.