Rotational Atherectomy Research Articles

Covered Endovascular Reconstruction of the Iliac Artery Bifurcation (CERIB).

The aim of this study was to present the covered endovascular reconstruction of the iliac artery bifurcation (CERIB) technique as a revascularization option for aorto-iliac occlusive disease (AIOD) involving the iliac artery bifurcation. This was a retrospective single-center study including all patients undergoing a CERIB procedure from January 2021 until December 2022. Covered endovascular reconstruction of the iliac artery bifurcation procedures were performed percutaneously with bilateral femoral access, excepting cases where simultaneous open femoral artery reconstruction was required due to the extension of peripheral arterial occlusive disease. Standard patient, procedural, and follow-up (FU) data including survival and arterial reinterventions were gathered and analyzed. A total of 13 patients were included (11/13 male, median age=70 [60-76] years). Additional open and/or endovascular procedures included endarterectomy of the femoral bifurcation (n=6), rotational atherectomy (n=2), and 1 axillary artery cutdown for upper limb access (n=1). Median operating time was 2.9 hours (1.5-4.9 hours); median radiation duration and dose were 28.4 (14.3-63.3 minutes) and 4090.6 (384.4-9430.1 cGray/cm2), respectively. The stent grafts used for CERIB were BeGraft peripheral n=31, BeGraft Aortic n=4 and BeGraft peripheral plus n=1 (Bentley InnoMed GmbH, Hechingen, Germany). In 2 patients with prior stenting of the common iliac artery (CIA), only the internal and external iliac arteries (IIA and EIA) were treated in this study, and in 2 cases, additional uncovered stents were required for relining. Technical success was 100%. During a midterm FU (median 18 [4-31] months), 2 patients died from cardiovascular reasons and 1 patient with prior iliac stenting required reinterventions for recurring occlusion. Covered endovascular reconstruction of the iliac artery bifurcation is a straightforward option for treating AIOD involving the iliac artery bifurcation that allows preservation of internal iliac artery perfusion and shows good early and midterm results. Prior iliac artery stenting may be a risk factor for early occlusion after CERIB. Aorto-iliac occlusive disease with involvement of the internal iliac artery is encountered regularly in vascular surgical practice, but the internal iliac artery is often not included in the revascularization strategy. The present article will increase the awareness for the relevance of including the internal iliac artery in revascularization strategies and presents CERIB as another method to be added to the armamentarium of (endo-)vascular surgeons and interventionalists.

The Usefulness of Intravascular Ultrasound and Optical Coherence Tomography in Patients Treated with Rotational Atherectomy: An Analysis Based on a Large National Registry.

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have been shown to improve the clinical outcomes of percutaneous coronary interventions (PCIs) in selected subsets of patients. The aim was to investigate whether the use of OCT or IVUS during a PCI with rotational atherectomy (RA-PCI) will increase the odds for successful revascularization, defined as thrombolysis in myocardial infarction (TIMI) 3 flow. Data were obtained from the national registry of PCIs (ORPKI) maintained by the Association of Cardiovascular Interventions (AISN) of the Polish Cardiac Society. The dataset includes PCIs spanning from January 2014 to December 2021. A total of 6522 RA-PCIs were analyzed, out of which 708 (10.9%) were guided by IVUS and 86 (1.3%) by OCT. The postprocedural TIMI 3 flow was achieved significantly more often in RA-PCIs guided by intravascular imaging (98.7% vs. 96.6%, p < 0.0001). Multivariable analysis revealed that using IVUS and OCT was independently associated with an increased chance of achieving postprocedural TIMI 3 flow by 67% (odds ratio (OR), 1.67; 95% confidence interval (CI): 1.40-1.99; p < 0.0001) and 66% (OR, 1.66; 95% CI: 1.09-2.54; p = 0.02), respectively. Other factors associated with successful revascularization were as follows: previous PCI (OR, 1.72; p < 0.0001) and coronary artery bypass grafting (OR, 1.09; p = 0.002), hypertension (OR, 1.14; p < 0.0001), fractional flow reserve assessment during angiogram (OR, 1.47; p < 0.0001), bifurcation PCI (OR, 3.06; p < 0.0001), and stent implantation (OR, 19.6, p < 0.0001). PCIs with rotational atherectomy guided by intravascular imaging modalities (IVUS or OCT) are associated with a higher procedural success rate compared to angio-guided procedures.

Clinical outcomes of single- versus two-stent PCI technique in severely calcified true bifurcation lesions after rotational atherectomy.

Severely calcified coronary bifurcations complicate percutaneous coronary interventions (PCI) and often necessitate dedicated lesion preparation. We compared the outcomes of single- versus two-stent techniques for treating heavily calcified true bifurcation lesions following rotational atherectomy (RA). Among patients receiving RA for severely calcified true bifurcations at a single center, 59 were treated with a single stent, and another 59 received two stents. We analyzed in-hospital adverse outcomes and 1-year rates of the bifurcation-oriented composite endpoint (BOCE), defined as cardiac death, target bifurcation myocardial infarction (TB-MI), or target bifurcation revascularization (TBR). The single-stent arm was associated with more in-hospital adverse outcomes (adj. OR, 6.13; 95% CI, 1.34-28.0; p = 0.019), driven by higher peri-procedural MI rates (18.6% vs. 5.1%, p = 0.043) and more side branch compromise (13.6% vs. 0%, p = 0.006). After 1year, both techniques had comparable 1-year BOCE (adj. HR, 0.38; 95% CI, 0.12-1.23; p = 0.106). We observed a significant interaction between the treatment technique and the presence of LM bifurcation (p interaction = 0.012), favoring single-stent technique in patients with non-LM bifurcations (HR 0.14, 95% CI 0.03-0.68; p = 0.015). Notably, the single-stent technique had lower rates of TBR (2% vs. 15%, p log-rank = 0.026) after 1year. Patients with severely calcified true bifurcation lesions, treated with RA followed by a single stent implantation, had more in-hospital adverse outcomes compared to those treated with two stents. However, the superior outcomes of the two-stent technique did not translate into improved long-term results. In fact, the two-stent technique was even associated with higher rates of revascularization after 1year.

Mechanism of Stent Failure in Patients With Eruptive Calcified Nodule Treated With Rotational Atherectomy

BackgroundPercutaneous coronary intervention (PCI) for lesions with eruptive calcified nodules (CNs) is associated with worse outcomes compared with that for other calcified lesions. We aimed to clarify the relationship between eruptive CNs at index PCI, optical coherence tomography (OCT) findings at the 8-month follow-up, and clinical outcomes using serial OCT. MethodsThis retrospective observational study used data from a prospective, single-centre registry. We conducted consecutive PCI for calcified lesions requiring rotational atherectomy (RA) with OCT guidance. We categorized 51 patients (54 lesions) into those with (16 patients [16 lesions]) and without eruptive CNs (35 patients [38 lesions]). ResultsPost-PCI, stent expansion was comparable between the 2 groups, and CN-like protrusion was found in 75% of lesions with eruptive CNs. Follow-up OCT at 8 months revealed in-stent CNs in 54% of treated eruptive CN lesions, whereas lesions without eruptive CNs lacked in-stent CNs. Multivariate linear regression analysis demonstrated that eruptive CN was associated with maximum neointimal tissue (NIT) thickness (regression coefficient 0.303; 95% confidence interval, 0.057-0.549; P = 0.02). Consequently, patients with eruptive CNs exhibited a higher clinically driven target lesion revascularization (TLR) rate than did those without at 1 year (31.3% vs 2.9%, P = 0.009) and 5 years (43.8% vs 11.4%, P = 0.02). TLR primarily occurred in lesions with maximum eruptive CN arc angles > 180°. ConclusionsFollowing RA treatment with acceptable stent expansion, eruptive CNs before PCI correlated with greater NIT formation with in-stent CNs, resulting in a higher TLR rate, particularly in lesions with maximum eruptive CN arc angles exceeding 180°.

Sex-Specific Analysis of Mid-Term Outcomes of Atherectomy-Assisted Endovascular Treatment in Severe Peripheral Arterial Disease.

Background: Endovascular treatment of lower-extremity peripheral disease (PAD) is associated with higher complication rates and suboptimal outcomes in women. Atherectomy has shown favourable outcomes in calcified lesions, minimising the incidence of stent placement caused by recoil or flow-limiting dissection. To date, there are no published mid-term outcomes evaluating the performance of atherectomy differentiated by sex. This study aims to evaluate sex-specific outcomes and prognostic factors affecting the results of atherectomy-assisted endovascular treatment in severe PAD. Methods: A retrospective analysis was conducted at a single centre in Germany, initiated by physicians and not sponsored by industry, on patients presenting with Rutherford categories ranging from III to V and featuring de novo occlusive or stenotic lesions of the superficial femoral (SFA) and/or popliteal arteries. The intervention involved rotational atherectomy-assisted angioplasty utilising the Jetstream (Boston, US®) device. The point of interest of this study was postinterventional clinical improvement as well as mid-term outcomes, including primary patency, over a targeted 2-year follow-up period. Statistical analysis utilised Cox regression (survival analysis) to calculate hazard ratios according to sex category. Comparative survival analysis was performed using the log-rank test and visually represented through Kaplan-Meier curves. Risk factors associated with absence of clinical improvement were examined across both sex groups utilising the chi-square or Fisher exact test, as appropriate. Results: A total of 98 patients (103 limbs) were initially included, with >75% having moderate-to-severe lesion calcification (>50%). A total of 84 patients (97 limbs, 62 male and 35 female) proceeded to a 2-year follow-up (mean 16.4 months for males and 16.1 for females) after a successful index procedure. Age distribution, Rutherford class, diabetes, chronic kidney disease (CKD), target vessel, lesion type, and length were balanced among both groups. Similar primary patency rates, of 89% among female and 91% among male limbs, were observed (p = 0.471). Female patients exhibited a lower rate of clinical improvement based on the Rutherford scale in comparison to males (80.6% vs. 94.5%, p = 0.048). CDK was the only significant prognostic factor across pooled data (odds ratio for CKD: 15.15, p < 0.001). Conclusions: Rotational atherectomy showed comparably high rates of mid-term primary patency, with low rates of bailout stent placement. These findings highlight the beneficial use of atherectomy in female patients who are per se at risk for higher rates of complications during and after endovascular interventions.

Development and Validation of Artificial Intelligence-Based Algorithms for Predicting the Segments Debulked by Rotational Atherectomy Using Intravascular Ultrasound Images

We develop and evaluate an artificial intelligence-based algorithm that uses pre-rotation atherectomy (RA) intravascular ultrasound (IVUS) images to automatically predict regions debulked by RA. A total of 2106 IVUS cross-sections from 60 patients with de novo severely calcified coronary lesions who underwent IVUS-guided RA were consecutively collected. The two identical IVUS images of pre- and post-RA were merged, and the orientations of the debulked segments identified in the merged images were marked on the outer circle of each IVUS image. The artificial intelligence model was developed based on ResNet (deep residual learning for image recognition). The architecture connected 36 fully connected layers, each corresponding to one of the 36 orientations segmented every 10°, to a single feature extractor. In each cross-sectional analysis, our artificial intelligence model achieved an average sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 81%, 72%, 46%, 90%, and 75%, respectively. In conclusion, the artificial intelligence-based algorithm can use information from pre-RA IVUS images to accurately predict regions debulked by RA and will assist interventional cardiologists in determining the treatment strategies for severely calcified coronary lesions.

SHOULD WE BE CONCERNED ABOUT USING INTRAVASCULAR LITHOTRIPSY ON THE LEFT MAIN? INSIGHT FROM ROLLING STONE RETROSPECTIVE REGISTRY

Abstract Background The use of rotational atherectomy is currently prevalent in the treatment of left main coronary artery lesions. However, it often necessitates the use of a large burr to achieve adequate debulking, which, in turn, demands highly experienced operators. Intravascular lithotripsy (IVL) is a promising, user–friendly and increasingly employed technique for calcific plaque modification before percutaneous coronary intervention. Although in many cath labs it is now routinely used to treat lesions of the three main coronary arteries, there are still concerns regarding its use in the left main, primarily due to prolonged inflations required for its optimal efficacy. Methods We conducted a retrospective analysis using data from the multicenter retrospective Rolling Stone registry. The analysis involved data from 474 patients, with a stratification between IVL procedures involving left main coronary artery (46 patients) and those that did not (428 patients). The primary effectiveness endpoint was procedural success (defined as achieving residual stenosis &amp;lt; 20% with TIMI III flow); secondary endpoints included the rate of procedural related adverse events, in hospital adverse events and MACE rate at 30 days and 6 months. Results Between April 2018 and January 2023, a total of 474 underwent IVL procedures. Most patients presented with calcific lesion requiring lithotripsy in non–left main segments, while IVL was performed on the left main artery in 46 patients. No significative differences were found on baseline characteristics between LM and non–LM groups. Treatment of IVL–LM lesion was marked by a high procedural success rate (97.8%) and a low incidence of procedural and peri–procedural complications. However, there was a higher rate of contrast–induced acute kidney injury in patients treated in LM (6.5% vs. 1.6%, p=0.030), although no other differences for in–hospital outcomes were observed. Furthermore, there were no differences in 30–day and 6–month follow–up outcomes between the two groups. Conclusions This study suggests that employing intravascular lithotripsy in the left main coronary artery is not only a safe procedure but also produces excellent results comparable to its application in other coronary branches. This provides a substantial level of confidence in the safety and effectiveness of IVL when used in this specific context.

Stent Ablation by Rotational Atherectomy for Management of Resistant Lesions within and across the Stent Struts in Coronary Arteries

Background: Non-dilatable stent underexpansion has limited treatment options. Stent ablation by rotational atherectomy (RA) for the management of non-dilatable coronary stents is an off-label strategy. The principle of stent ablation by RA of underexpanded stent relies on modification of both stent and underlying calcium. This study aims to describe and compare the use of RA for non-dilatable lesions in two anatomical categories: group 1 (within the stent struts) and group 2 (across the stent struts). Methods: A total of seven patients who had undergone stent ablation by RA were analysed. Indications for revascularisation were acute coronary syndrome or chronic stable angina. Two groups are described: RA within underexpanded stents (group 1) and across the stent struts (across stented bifurcation; group 2). Results: The burr:artery ratio was 0.6 ± 0.1 in group 1 and 0.5 in group 2 (p=0.24). The maximum rotational speed was 154,400 ± 2,500 and 155,000 rpm in the two groups. The total number of RA runs was 3.6 ± 0.90 in group 1 and 7.0 ± 2.8 in group 2, respectively, p=0.04. Procedural success was achieved in all cases with no complications. Conclusion: RA is a feasible bailout option for resistant non-dilatable lesions within and across the stent struts.

Comparison of interventional treatment options for coronary calcified nodules: A sub-analysis of the ROTA.shock trial

BackgroundThe optimal treatment for coronary calcified nodules (CNs) is still unclear. The aim of this study was to compare the modification of these lesions by coronary intravascular lithotripsy (IVL) and rotational atherectomy (RA) using optical coherence tomography (OCT). MethodsROTA.shock was a 1:1 randomized, prospective, double-arm multi-center non-inferiority trial that compared the use of IVL and RA with percutaneous coronary intervention (PCI) in severely calcified lesions. In 19 of the patients out of this study CNs were detected by OCT in the target lesion and were treated by either IVL or RA. ResultsThe mean angle of CNs was significantly larger in final OCT scans than before RA (92 ± 17° vs. 68 ± 7°; p = 0.01) and IVL (89 ± 18° vs. 60 ± 10°; p = 0.03). The CNs were thinner upon final scans than in initial native scans (RA: 17.8 ± 7.8 mm vs. 38.6 ± 13.1 mm; p = 0.02; IVL: 16.5 ± 9.0 mm vs. 37.2 ± 14.3 mm; p = 0.02). Nodule volume did not differ significantly between native and final OCT scans (RA: 0.66 ± 0.12 mm3 vs. 0.61 ± 0.33 mm3; p = 0.68; IVL: 0.64 ± 0.19 mm3 vs. 0.68 ± 0.22 mm3; p = 0.74). Final stent eccentricity was high with 0.62 ± 0.10 after RA and 0.61 ± 0.09 after IVL. ConclusionRA or IVL are unable to reduce the volume of the calcified plaque. CN modulation seems to be mainly induced by the stent implantation and not by RA or IVL.

OR5-1 | Intravascular Lithotripsy Compared With Rotational Atherectomy for Calcified Coronary Lesions: A Meta-Analysis of Outcomes

OR5-1 | Intravascular Lithotripsy Compared With Rotational Atherectomy for Calcified Coronary Lesions: A Meta-Analysis of Outcomes

Rotational atherectomy and intravascular lithotripsy (RotaTripsy) in a massive heavily calcified coronary aneurysm in a young woman.

Rotational atherectomy and intravascular lithotripsy (RotaTripsy) in a massive heavily calcified coronary aneurysm in a young woman.

ASSESSMENT OF SAFETY AND FEASIBILITY OF ROTATIONAL ATHERECTOMY (RA) VERSUS CONVENTIONAL STENTING IN PATIENTS WITH CHRONIC TOTAL OCCLUSION (CTO) LESIONS

Chronic total occlusion (CTO) sores in coronary arteries present a challenge in percutaneous coronary intervention (PCI) because of their complex anatomy and high rates of procedural failure. Objectives: In this comparative study, we aim to investigate the safety and feasibility of rotational atherectomy (RA) versus conventional stenting in patients with chronic total occlusion (CTO) lesions. Methods: This comparative study was conducted at Ayub teaching hospital from September 2023 to December 2023. Data was collected from 110 patients from both genders. Patients aged &gt; 18 years and diagnosed with chronic total occlusion (CTO) lesions in coronary arteries confirmed by coronary angiography were included in the study. Baseline demographic and clinical data, including age, gender, comorbidities, and angiographic characteristics, were collected for each participant. Additionally, procedural details such as the type of intervention, rotational atherectomy, conventional stenting, procedural time, fluoroscopy time, contrast volume, and any adverse events encountered during the procedure were recorded. Results: Data were collected from 110 patients from both genders. The mean age of participants in the Rotational Atherectomy (RA) group was 62.4 ± 7.3 years, while in the Conventional Stenting group, it was 61.8 ± 6.9 years. There were 40 males and 15 females in the RA group, compared to 38 males and 17 females in the Conventional Stenting group. The prevalence of diabetes mellitus was 42.0% in the RA group and 45.5% in the Conventional Stenting group. Left ventricular ejection fraction (LVEF) was 53.7 ± 4.2% in the RA group and 54.1 ± 4.5% in the Conventional Stenting group. The RA group showed a success rate of 81.8%, and the conventional stenting group achieved a success rate of 90.9%. However, the RA group experienced slightly higher rates of major procedural complications (9.1% vs. 5.5%) and minor procedural complications (12.7% vs. 10.9%) than the conventional stenting group. Conventional stenting group, the mean change was -1.2 ± 0.7. Additionally, the incidence of target lesion revascularisation (TLR) was observed in 8 patients (14.5%) in the RA group and 12 patients (21.8%) in the conventional stenting group. Furthermore, major adverse cardiovascular events (MACE) occurred in 9 patients (16.4%) in the RA group and 11 patients (20.0%) in the conventional stenting group. Conclusion: It is concluded that both rotational atherectomy (RA) and conventional stenting are effective and safe treatment options for patients with chronic total occlusion (CTO) lesions. Our findings suggest that both strategies yield comparable procedural success rates, complication rates, and efficacy outcomes, including myocardial infarction frequency, troponin levels, and left ventricular ejection fraction changes.

Coronary laser with simultaneous contrast injection for the treatment of stent underexpansion.

Stent underexpansion is a challenge in interventional cardiology. Some off-label treatments, such as rotational atherectomy, intravascular lithotripsy (IVL) and coronary lasing, have been used to overcome the problem. The purpose of this study is to evaluate the safety and efficacy of coronary laser atherectomy with simultaneous contrast injection and subsequent balloon dilation to optimize stent expansion. Coronary laser atherectomy with simultaneous contrast injection was used. After lasing, non-compliant balloon dilation at high pressure was performed to overcome the underexpanded point. The average increase in the minimum stent area (MSA) was measured by intravascular ultrasound (IVUS), and any complication related to the technique was evaluated. Additionally, major adverse cardiovascular events (MACE), consisting of death from any cause, new myocardial infarction (MI) and target lesion revascularization (TLR), were scrutinized in a long-term follow-up. Sixteen underexpanded stents were treated with laser between August 2017 and November 2022. In all cases but one, IVUS was used to evaluate the MSA before and after lasing. The MSA showed an average increase of 2.34 ± 1.57 mm² (95% confidence interval [CI]: 1.47-3.21; p < 0.001) after laser application and balloon inflation. No complication related to the technique was detected. During a follow-up period of a median (interquartile range) of 457 (50-973) days, the combined MACE assessed by Kaplan-Meier estimator showed an event-free rate of 0.82 (95% CI: 0.59-1). Coronary laser with simultaneous contrast injection is a safe method to optimize a stent underexpansion, with an acceptable event-free rate in long-term follow-up.

Current Management of In-Stent Restenosis.

In-stent restenosis (ISR) remains the primary cause of target lesion failure following percutaneous coronary intervention (PCI), resulting in 10-year incidences of target lesion revascularization at a rate of approximately 20%. The treatment of ISR is challenging due to its inherent propensity for recurrence and varying susceptibility to available strategies, influenced by a complex interplay between clinical and lesion-specific conditions. Given the multiple mechanisms contributing to the development of ISR, proper identification of the underlying substrate, especially by using intravascular imaging, becomes pivotal as it can indicate distinct therapeutic requirements. Among standalone treatments, drug-coated balloon (DCB) angioplasty and drug-eluting stent (DES) implantation have been the most effective. The main advantage of a DCB-based approach is the avoidance of an additional metallic layer, which may otherwise enhance neointimal hyperplasia, provide the substratum for developing neoatherosclerosis, and expose the patient to a persistently higher risk of coronary ischemic events. On the other hand, target vessel scaffolding by DES implantation confers relevant mechanical advantages over DCB angioplasty, generally resulting in larger luminal gain, while drug elution from the stent surface ensures the inhibition of neointimal hyperplasia. Nevertheless, repeat stenting with DES also implies an additional permanent metallic layer that may reiterate and promote the mechanisms leading to ISR. Against this background, the selection of either DCB or DES on a patient- and lesion-specific basis as well as the implementation of adjuvant treatments, including cutting/scoring balloons, intravascular lithotripsy, and rotational atherectomy, hold the potential to improve the effectiveness of ISR treatment over time. In this review, we comprehensively assessed the available evidence from randomized trials to define contemporary interventional treatment of ISR and provide insights for future directions.

Combined Treatment of Native Femoropopliteal Occlusions in Chronic Limb-Threatening Ischemia Using Atherectomy Debulking and a New Sirolimus Drug-Coated Balloon (SELUTION SLR)

Abstract Objective The aim of this study was to report the primary outcomes of a pilot study investigating the safety and efficacy of sirolimus drug-coated balloons (SELUTION) for endovascular postatherectomy treatment of native occluded femoropopliteal lesions in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods This study analyzes a cohort of CLTI patients with femoropopliteal artery occlusions treated with combined rotational atherectomy and postatherectomy angioplasty using the SELUTION device. The primary outcome measures were amputation-free survival (AFS) defined as time to major limb (above ankle) amputation of the index leg or death from any cause. Secondary outcome measures included technical success, overall survival, major amputation of the index leg, major adverse limb event (MALE) defined as major amputation or any further major revascularization intervention of the treated segment during the follow-up period and primary patency at 12 months. Results Between April 2021 and January 2022, nine patients (mean age: 64.0 ± 8.4, 66.7% male) with femoropopliteal occlusive lesions (mean lesion length: 141.1mm, range: 40–400) were treated with the above-combined approach. Technical success was 100%. At 12 months, the AFS was 88.9%, with one death and zero major amputations (88.9% survival and 100% limb salvage, respectively); only two patients (22.2%) suffered a MALE; primary patency was 75%. No adverse events related to the sirolimus drug-coated balloon nor to the atherectomy device were observed. Conclusion Combining sirolimus drug-coated balloon and atherectomy for treatment of femoropopliteal occlusions in CLTI patients is a safe and effective approach achieving satisfactory patency and adverse event rates.

Sealing of Iatrogenic Distal Coronary Artery Perforation by Liquid Embolization Agent—A Case Report

Percutaneous coronary intervention (PCI) is one of the most commonly performed cardiovascular interventions to treat significant coronary artery stenosis. Although a safe procedure, it carries the risk of complications like coronary artery perforation (CAP), bleeding, stroke, and acute kidney injury rarely resulting in death. The incidence of CAP is 0.84% of all PCI procedures and the incidence is increasing as cardiologists are accepting more and more challenging cases. CAP is caused by a guidewire (GW) or a vessel tear from balloon angioplasty, stenting, or rotational atherectomy. Though the majority of CAPs do not result in cardiac tamponade, some do lead to tamponade and death. The majority of distal wire perforations respond to prolonged balloon inflation, coils, glue, or fat embolization. Herein, we report a case of distal CAP in a 63-year-old woman occurring following left circumflex artery PCI caused by the exiting of coronary GW. The CAP was successfully sealed by the liquid embolization technique using ONYX. First described in 1990, Onyx is an elastic polymer composed of ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide and mixed with micronized tantalum powder (Onyx). The Onyx is predominantly used by interventional radiologists while performing neurovascular and peripheral vascular interventions. There were only a few case reports of plugging of CAPs using Onyx. Our case highlights the safety and feasibility of closing distal CAPs using Onyx.

A Complex Case with a Completely Percutaneous Solution: Treatment of a Severe Calcific Left Main in a Patient with Low-Flow Low-Gradient Aortic Stenosis

Background: This case study explores an integrated approach to managing a complex cardiac condition, presenting a comprehensive single-session intervention. This includes balloon valvuloplasty using a Nucleus 18 mm balloon, complex angioplasty with rotational atherectomy (rotablator) targeting calcified lesions in the left main and left anterior descending artery, and Transcatheter Aortic Valve Implantation (TAVI) with a 23 mm Sapien 3 valve, all performed on an 81-year-old woman. Furthermore, this report underscores the strategic left atrial appendage closure conducted three months post-procedure due to the patient’s elevated hemorrhagic risk. Case presentation: Facing critical coronary and valvular pathologies, the patient underwent a meticulously planned, single-session intervention. The process began with a balloon valvuloplasty using a Nucleus 18 mm balloon to address the aortic stenosis. This was followed by a high-risk angioplasty, during which the Impella CP device provided hemodynamic support and rotational atherectomy was employed to address the calcified coronary artery disease effectively. The same session saw the successful execution of TAVI using a 23 mm Sapien 3 valve. The comprehensive approach notably diminished procedural complications, illustrating the benefits of an integrated treatment pathway in managing high-risk patients. Three months later, the patient underwent a left atrial appendage closure, a critical move considering her high risk of hemorrhage. This procedure also provided an opportunity to assess the favorable outcomes of the previous angioplasty. Conclusion: This case validates the feasibility and efficacy of performing multiple advanced percutaneous interventions in a single session for high-risk cardiac patients. It underscores the crucial role of innovative and personalized treatment strategies in improving patient outcomes, particularly in complex clinical scenarios. Moreover, the case exemplifies the essential relationship between immediate, comprehensive intervention and subsequent follow-up procedures in ensuring optimal long-term patient care.

RotaTripsy Risk and Rewards: Findings from a Registry of Patients Undergoing Combined Rotational Atherectomy and Intravascular Lithotripsy

Background: Heavily calcified coronary artery lesions are a therapeutic challenge for interventional cardiologists worldwide. Recently, RotaTripsy has gained popularity as a calcium modification technique prior to stent implantation. In this procedure, operators employ rotational atherectomy to debulk luminal calcium alongside intravascular lithotripsy to fracture deeper concentric calcifications. Aims: To identify the demographics and outcomes of patients undergoing RotaTripsy. Methods: Baseline clinical characteristics, procedural details and in-hospital and 30-day outcomes were recorded and reported for a registry of patients in whom combined rotational atherectomy and intravascular lithotripsy were performed in one procedure at the discretion of the primary operator at one high-volume tertiary centre. Results: Over 2020–2022, 57 consecutive patients underwent RotaTripsy during percutaneous coronary intervention. In this cohort, 23 (40%) had acute coronary syndrome and three (5.3%) had an ST-elevation MI. Additionally, 10 (18%) were on dialysis, 20 (35%) had unprotected left main coronary artery/left main coronary artery equivalent lesions, seven (12%) had acute heart failure and nine (16%) required intraprocedural intra-aortic balloon pump support. Of the procedures, 51 (89.5%) were successful, defined as successful stent implantation and &lt;30% residual angiographic stenosis without in-hospital major adverse cardiac events. Complications included slow/no-reflow (six patients; 11%), cerebrovascular events (three patients; 5.3%), in-hospital MI (three patients; 5.3%) and mortality (three patients; 5.3%). The 30-day MI rate was 5.3% (three patients) and the mortality rate was 7.0% (four patients). Conclusion: RotaTripsy was successful in facilitating stent delivery and restoring flow, even in a relatively sick cohort. Nevertheless, complication rates were high, reflecting the challenge of treating these complex patients.

Lower revascularization rates after high-speed rotational atherectomy compared to modified balloons in calcified coronary lesions: 5-year outcomes of the randomized PREPARE-CALC trial.

In the PREPARE-CALC trial, severely calcified lesion preparation with rotational atherectomy (RA) before biodegradable polymer sirolimus-eluting stent (SES) implantation demonstrated higher procedural success and comparable rates of acute lumen gain and late lumen loss compared to modified balloons (MB) (scoring/cutting). We aimed to analyze the 5-year outcomes of both lesion preparation strategies. PREPARE-CALC randomly assigned 200 patients 1:1 to MB or RA, followed by SES implantation. The principal endpoint of the current analysis was target vessel failure (TVF) at 5years. At 5years, MB had comparable rates of TVF to RA (19% vs. 21%, HR 1.14, 95% CI 0.60-2.16, p = 0.687). Subgroup analysis showed a lesion length treatment interaction, favoring MB for short lesions and RA for long ones (p for interaction = 0.042). Target lesion revascularization (TLR) was significantly less common with RA (12 vs. 3%, HR 0.28, 95% CI 0.08-0.98, p = 0.048). In a multivariate analysis, RA was independently protective against TLR (adj. HR 0.17, 95% CI 0.04-0.78, p = 0.022), while ostial lesions were associated with higher TLR independent of treatment strategy (adj. HR 11.3, 95% CI 2.98-42.6, p < 0.001). In patients with severely calcified coronary lesions, using MB or RA for lesion preparation followed by biodegradable polymer SES implantation was associated with comparable rates of TVF at 5years. However, a significant reduction of TLR was observed after RA. PREPARE-CALC is the first randomized trial showing potential clinical advantages of RA over MB during long-term follow-up. URL: https://www. gov . Unique identifier: NCT02502851.

Gender Differences in the Short and Long-Term Outcomes Following Rotational Atherectomy: A Meta-Analysis

BackgroundRotational atherectomy (RA) is used to address complex calcified coronary lesions but data regarding the association between gender and outcomes of patients undergoing RA remained uncertain. We aimed to investigate the short and long-term outcomes of patients undergoing RA based on sex. MethodsA systematic literature search was performed in PubMed, Embase and Cochrane databases from its inception until August 2023 for relevant studies. Endpoints were pooled using the DerSimonian and Laird random-effects model as odd ratio (OR) with 95% confidence intervals (CI). Results7 studies with 8,490 patients (2,565 women and 5,925 men) undergoing RA were included in the study. In terms of periprocedural outcomes, women had a higher risk of in-hospital mortality (OR 2.00, 95% CI 1.08-3.68, p=0.03), coronary dissection (OR 1.80, 95% CI 1.05-3.10, p=0.03), coronary perforation (OR 1.96, 95% CI 1.19-3.23, p=0.01), and stroke (OR 4.22, 95% CI 1.06-16.82, p=0.04) compared to men. There were no significant differences between women and men in terms of MACE (OR 1.43, 95% CI 0.69-2.94, p=0.33), MI (OR 1.35, 95% CI 0.87-2.08, p=0.18), bleeding (OR 1.71, 95% CI 0.88-3.30, p=0.11), and cardiac tamponade (OR 2.30, 95% CI 0.45-11.68, p=0.32). Over a follow-up period of 3 years, results of meta-analysis showed that women had a higher risk of all-cause mortality (OR 1.45, 95% CI 1.19-1.77, p<0.001), long-term MACE (OR 1.38, 95% CI 1.10-1.74, p=0.01), and long-term stroke (OR 3.41, 95% CI 1.63-7.17, p<0.001). The risk of long-term MI was found to be similar between both gender (OR 1.45, 95% CI 0.95-2.22, p=0.09). ConclusionIn conclusion, female gender is associated with adverse periprocedural and long-term outcome following RA. Women consistently demonstrated higher risk of in-hospital mortality, coronary dissection, coronary perforation, and stroke in the periprocedural period. Long-term follow-up further highlighted a heightened risk for women in terms of all-cause mortality and stroke.