Abstract
Objective Heavy calcifications remain formidable challenges to PCI, even for well-experienced operators. However, rotational atherectomy (RA)-induced coronary perforations (CPs) still could not be obviated. This study was to explore incidence and mechanisms of RA-induced CP in real-world practice. Knowing why CPs occur in RA should help operators avert such mishaps. Method Patients who received coronary RA from April 2010 to December 2019 with keywords related to perforations were retrieved from database. The procedure details, angiography, and clinical information were reviewed in detail. Results A total of 479 RAs were performed with 11 perforations in 10 procedures among 9 patients documented. The incidence of RA-induced CP was 2.1%. The RA vessels were distributed in different territories, including first diagonal branch. Most CPs could be treated conservatively, but prolonged profound shock predisposed to poor outcome. CPs caused by rotawire tip occurred in 18.2% of cases, inappropriately sized burrs in 18.2% of cases, and rotawire damage with subsequent transection and perforation in another 18.2% of cases. A total of 5 (45.5%) perforations were caused by unintended and unnoticed bias cutting into noncalcified plaques (4, 36.4%) or through calcified vessel wall (1, 9.1%). The mechanisms for certain CPs were unique and illustrated in diagrams. Conclusion CPs due to RA occur in certain percentage of patients. The mechanisms for CPs are diverse. Wire damage with subsequent transection could occur due to inappropriately repetitive burr stress on the wire body. A significant portion was due to unintended and unnoticed bias cutting into noncalcified plaque or through calcified vessel wall.
Highlights
Percutaneous coronary intervention (PCI) has become well-recognized modality for treating coronary artery disease, even for complex lesions
A total 479 rotational atherectomy (RA) were performed at our cath labs and a total of 11 perforations in 10 procedures among 9 patients secondary to RA per se were documented with an incidence of 2.1% (10/479). e mean age was 75.9 (66–85) years. e demographic data of these 9 patients are presented in Supplementary Table 1
One patient (Case 7) suffered from 2 perforations (LCX proper and far distal LCX) in 1 procedure, whereas another 1 patient (Case 8) suffered from 2 perforations in 2 separate procedures as she had to endure bail-out procedure for another vessel after the first one precipitated shock due to RA-related Cardiology perforations (CPs) in one vessel. e procedure details are presented in Supplementary Table 2
Summary
Percutaneous coronary intervention (PCI) has become well-recognized modality for treating coronary artery disease, even for complex lesions. Heavy calcification could be eccentric or concentric, located at acute angulations or in long lesions with multiple bends, and encountered in acute coronary syndrome. Ough intravascular lithotripsy and orbital atherectomy could share part of work to treat coronary calcification [4], rotational atherectomy (RA, Boston Scientific, Natick, MA) has long-lasting history in the coronary interventions and is more familiar to most interventionists. Ough incidences of CP following RA had been reported before [5, 6, 9], the exact mechanisms for perforation were less well investigated and characterized [6, 10,11,12], despite several predictors are well known [7]. Knowing why CPs occur in rotablation should help operators avoid such mishaps in the future
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