Feasibility and Safety of Rotational Atherectomy in a Rural Centre Without On-Site Cardiac Surgery

Rotational atherectomy has become increasingly common in centres without on-site cardiac surgery to treat heavily calcified coronary artery disease. However, there is limited evidence on its safety in rural centres with significant travel distances from tertiary centres with cardiac surgery.

This is a retrospective cohort study of all consecutive patients treated with rotational atherectomy in Mackay Base Hospital (MBH), Australia between March 2021 and September 2023. MBH is located 385 km away from the nearest tertiary centre with on-site cardiac surgery. The primary outcomes were procedural success, major peri-procedural complications, and all-cause mortality during hospitalisation. Secondary outcomes were major adverse cardiovascular events and complications at 30-day follow-up RESULTS: Of 20 patients treated with rotational atherectomy, the mean age was 72.3 years (standard deviation [SD]=9.9) and one-quarter were female. Their mean SYNTAX score was 20 (SD=9), while their mean EuroSCORE was 1.60 (SD=1.22). Target vessels included the right coronary artery (n=12; 60%), left anterior descending artery (n=7; 35%), and left circumflex artery (n=1; 5%). The mean rotablation burr diameter was 1.5 mm (SD=0.1), and all patients received at least one drug-eluting stent following atherectomy. The procedural success rate was 100%. Two major peri-procedural complications were observed; one may be attributable to rotational atherectomy, while the other was not specific: one intra-procedural cardiac arrest related to coronary slow-flow, and one upper mediastinal haematoma most likely related to accidental injury to a small arterial branch during the negotiation of a tortuous right brachiocephalic artery with a hydrophilic guidewire. No patient required emergency coronary artery bypass surgery. There was no all-cause mortality during hospitalisation and no major adverse cardiovascular event at 30-day follow-up.

Rotational atherectomy is feasible and safe in rural centres without on-site cardiac surgery. Careful case selection and a team-based approach with two operators are advised. Factors contributing to atherectomy safety, including operator volumes, adequate catheterisation laboratory team training, and strong partnership with the tertiary cardiac surgical centre, should be considered before establishing high-risk procedures in these centres.