Rotational atherectomy followed by drug-eluting stent implantation (Rota-DES): a rational approach for complex
1The Heart and Vascular Center, Segeberger Kliniken GmbH, Bad Segeberg, Germany. ahmed.khattab@segebergerkliniken.de
Insights
Rotational atherectomy, after falling out of favor, is resurging for complex percutaneous coronary interventions (PCI) with drug-eluting stents (DES). Research suggests pre-stent atherectomy may improve long-term outcomes, enhancing DES effectiveness.
Area of Science:
- Interventional Cardiology
- Cardiovascular Surgery
- Medical Devices
Background:
- Rotational atherectomy use declined due to unproven long-term benefits in percutaneous coronary interventions (PCI).
- The advent of drug-eluting stents (DES) has enabled PCI for more complex lesions and high-risk patients.
- Off-label DES use is linked to increased stent thrombosis, necessitating improved implantation techniques like aggressive lesion preparation.
Purpose of the Study:
- To evaluate the role of rotational atherectomy in preparing complex coronary lesions before drug-eluting stent implantation.
- To assess the potential add-on effect of rotational atherectomy on long-term outcomes when combined with DES.
- To highlight the importance of interventional training for rotational atherectomy techniques.
Main Methods:
- Review of limited studies on rotational atherectomy preceding DES implantation.
- Observation of promising short-term results and no long-term safety concerns in initial studies.
- An ongoing multicenter study investigating the effect of rotational atherectomy on complex calcified lesions before DES implantation.
Main Results:
- Limited studies indicate rotational atherectomy prior to DES implantation shows promising results with no immediate safety concerns.
- A subtle observation suggests a potential long-term benefit of rotational atherectomy before DES implantation.
- Rotational atherectomy is an effective tool for preparing challenging lesions to facilitate safe and effective DES delivery and expansion.
Conclusions:
- Rotational atherectomy is regaining importance for complex PCI, particularly with DES, due to its lesion preparation capabilities.
- Further research, including ongoing multicenter studies, is needed to confirm the long-term benefits of rotational atherectomy with DES.
- Interventional cardiology training programs must re-emphasize rotational atherectomy techniques to address the experience gap.
Abstract:
Rotational atherectomy has been regaining interest over the last couple of years after it almost has disappeared from most interventional catheterization laboratories for several years due to failure to prove its original concept of improving long term results of percutaneous coronary interventions (PCI) as was repeatedly shown in studies in the 1990s. Its revival coupled the introduction of drug-eluting stents (DES); these devices have led to treating much more complex lesions and high-risk patients by PCI. However, real-world experience suggested that off-label use of DES is associated with a higher rate of early and late stent thrombosis. Therefore, more attention is now being paid to the initial implantation technique of DES including aggressive lesion preparation to facilitate stent delivery and expansion. The limited studies with rot-ablation and DES showed promising results with no long term safety concerns. In these studies, a subtle observation was made suggesting that rot-ablation prior to DES implantation in such lesions may have an add-on effect on long term outcome compared to DES alone. An ongoing multicenter study is investigating such effect among complex calcified coronary lesions. Even if this additive benefit does not prove true, rot-ablation remains an efficient tool for preparing certain lesions to facilitate effective and safe DES implantation. Therefore, interventional training programs should focus on this difficult technique to bridge the gap of experience which resulted from neglecting it for several years. In this regard, dedicated courses at experienced sites as well as medical simulation may be appropriate.
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