Rotational Atherectomy in Clinical Practice

Unlike balloon dilation that results in the displacement of atherosclerotic plaque with multiple intimal tears, rotational atherectomy (RA) is based on the principle of differential cutting that allows for physical removal of inelastic atherosclerotic material while rendering the inner lumen surface smooth. Although plaque reduction by pulverization of atherosclerotic material into <10 μm particles has remained its central paradigm, the conceptual framework has shifted from the original approach of RA as a debulking strategy and, thus, applicable in a broad array of coronary lesions with large plaque burden, to a contemporary selective clinical utilization, with an emphasis mainly on plaque modification prior to stent implantation. This transition in conceptual understanding of the targeted effects of RA has been mirrored by a decreasing tendency in its use, from 20% in the mid 1990s to 1% to 3% according to contemporary reports. Today, RA is used selectively, mainly to disrupt the continuity of the calcium ring within the vessel wall and, thus, facilitate optimal drug-eluting stent (DES) implantation in patients with severely calcified de novo coronary lesions. ROTAXUS (Rotational Atherectomy Prior to Taxus Stent Treatment for Complex Native Coronary Artery Disease), as the only randomized trial to date that tested the strategy of routine lesion preparation with RA followed by DES implantation against stenting without RA, showed a higher rate of procedural success in patients undergoing RA, which, however, did not translate in long-term clinical benefit. These findings coincided with previous nonrandomized studies that had also supported RA as a means of achieving immediate procedural success in calcified coronary lesions, whereas long-term clinical benefit had not been consistently proven. However, the majority of the studies had an inherent limitation of nonstandardized preprocedural lesion assessment, which may have obscured the potential superiority of RA in the most complex lesion subset, considering the fact that inadequate stent deployment is often present in severely calcified coronary lesions, even after high-pressure balloon dilation. See Article by Sakakura et al