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Rotational atherectomy in resistant chronic total occlusions
Paolo Pagnotta1, Carlo Briguori, Ruggiero Mango
1Department of Cardiology, IRCCS Humanitas, Milan, Italy.
Insights
Rotational atherectomy effectively treats chronic total occlusions (CTOs) when standard guidewire techniques fail. This safe method overcomes challenging blockages, improving percutaneous recanalization success rates.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Percutaneous recanalization of chronic total occlusions (CTOs) can fail when devices cannot advance over a guidewire.
- This specific challenge occurs in approximately 7% of cases where guidewire passage is successful.
Purpose of the Study:
- To evaluate the effectiveness of rotational atherectomy in enhancing the success rate of percutaneous recanalization for CTOs.
- To assess the safety and utility of rotational atherectomy in difficult CTO cases.
Main Methods:
- A retrospective analysis of 648 CTO patients from January 2006 to October 2009.
- 45 patients with CTOs resistant to conventional recanalization were treated with rotational atherectomy (Rotablator group).
- Comparison with 603 CTOs treated using conventional techniques (Conventional group).
Main Results:
- Rotational atherectomy successfully crossed all but two lesions, leading to stent implantation.
- Rotablator group patients were older, had more comorbidities (e.g., chronic kidney disease), and longer CTO duration.
- Higher rates of peri-procedural myocardial infarction were observed in the Rotablator group (35% vs. 22%).
Conclusions:
- Rotational atherectomy provides a safe and effective solution for CTOs where conventional device advancement fails.
- This technique significantly improves the success of percutaneous recanalization in challenging CTO cases.
Objectives:
To assess the application of rotational atherectomy to improving the success rate of percutaneous recanalization of chronic total occlusion (CTO).
Background:
Although the inability to cross the occlusion with a guidewire is the reason for failure in the majority of cases, one of the most frustrating situations that may occur during a recanalization procedure is when a guidewire crosses successfully but it is impossible to advance any device over the wire through the occluded segment.
Methods:
From January 2006 to October 2009, 45/648 (7%) consecutive patients with CTO resistant to recanalization by conventional techniques were treated by high-speed rotational atherectomy (Rotablator group).
Results:
All but two lesions were successfully crossed by Rotablator and eventually treated by stent implantation. As compared to the 603 CTO treated by conventional techniques (Conventional group), the 45 patients in the Rotablator group were older, more often female, active smokers, with chronic kidney disease and higher rate of previous surgical revascularization. The CTO in the Rotablator group had a longer duration. Peri-procedural myocardial infarction was more frequent in the Rotablator group (35% vs. 22%; P = 0.044). Coronary perforation occurred only in three patients in the Conventional group and two of these patients needed urgent surgical intervention. No patient died from either group.
Conclusions:
The inability to cross a CTO with a balloon catheter occurs in approximately 7% of all CTOs that are successfully crossed with a guidewire. Rotational atherectomy is a safe and effective technique to overcome this frustrating situation.
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