Rotational atherectomy for treatment of occluded prosthetic grafts

Potentially, percutaneous rotational atherectomy (RA) can be used to open occluded prosthetic arterial bypass grafts with less morbidity than surgical catheter thrombectomy. However, RA could damage prosthetic grafts or produce significant distal emboli. To investigate this, acutely thrombosed and chronically occluded prosthetic grafts, harvested from dogs, were placed in an ex vivo perfusion system and recanalization was attempted using the TRAC-Wright rotational atherectomy system. Urokinase (UK) was delivered through the RA catheter in one-half of the procedures. Graft surface thrombogenicity and graft mechanical integrity after successful recanalization were determined and debris released during recanalization was collected. Results were compared to those from grafts opened by catheter thrombectomy. One hundred percent (22/22) of acute prosthetic graft occlusions and 39% (16/41) of chronic prosthetic graft occlusions were opened using RA, similar to results achieved using catheter thrombectomy. In addition, surface thrombogenicity after recanalization of acute graft occlusion with RA was lower than that after catheter thrombectomy (P < 0.05) and infusion of UK improved RA success in chronically occluded grafts (52% vs 25%). Debris generated during RA averaged 15-18 micrograms, equivalent to debris generated during catheter thrombectomy, and graft mechanical integrity was unaffected by recanalization using RA. Thus, rotational atherectomy is a minimally invasive means of safe and effective prosthetic graft recanalization that produces a less thrombogenic graft than thrombectomy.