ercutaneous rotational atherectomy is mainly utilized in contemporary interventional practice to alter lesion compliance, facilitating stent delivery and antirestenotic drug delivery at the site of the underlying lesion. This enables a percutaneous revascularization strategy in a group of patients who would otherwise require a surgical revascularization. We identify and present three novel uses for this device in percutaneous coronary and peripheral interventional procedures, which further expands the applications of rotational atherectomy.

       Rotational atherectomy (RA) has been utilized during percutaneous coronary interventions (PCI) for over a decade. It is particularly efficacious in ablating fibrocalcific plaque and facilitates PCI by enabling stent delivery. Although previously, RA was frequently utilized during PCI, enthusiasm for this device faded when a restenosis benefit over balloon angioplasty for both native lesions¹ and in-stent restenotic lesions^2,3 could not be demonstrated. RA is utilized in 3–5% of PCI procedures in contemporary practice,^4,5 primarily to facilitate PCI in calcified lesions, bifurcation lesions, ostial lesions, in-stent restenotic lesions and undilateable lesions. We queried a prospectively collected coronary and peripheral interventional database for all RA procedures performed at our institution between July 1, 2002 and June 30, 2004, to identify any novel uses of this device. RA was utilized in 2.1% of interventional procedures at our institution, with the majority of use being for traditionally recognized indications for this device. However, we identified and present here three novel uses for RA in contemporary interventional practice.

Niche Uses of Rotational Atherectomy
       1) Optimal stent expansion immediately after incomplete stent expansion with direct stenting. A 65-year-old man presented with accelerating angina and diagnostic coronary angiography revealed high-grade, two-vessel coronary artery disease (CAD) involving the proximal to mid-left anterior descending (LAD) artery (Figure 1A) and ostial posterior descending artery (PDA), and moderately depressed left ventricular systolic function. Percutaneous revascularization was performed with direct stenting of the mid-LAD with a 3.0 x 32 mm Express2 stent (Boston Scientific, Natick, Massachusetts). Proximal to this stent, a 3.5 x 12 mm Express2 stent was deployed at 18 atm. However, a significant residual stenosis persisted despite balloon dilatation with a non-compliant 3.5 x 15 mm NC Ranger balloon

Figure 1a

(A) High-grade stenotic lesions in the proximal and mid left anterior descending coronary artery (LAD). Right anterior oblique (RAO) cranial projection.

Figure 1c

(C) Rotational atherectomy burr at the proximal LAD undilateable stent site.

(Boston Scientific) performed up to 24 atm, at which point the balloon ruptured. Repeat dilatation with another balloon resulted in the same outcome, with the lesion failing to yield and a persistent residual stenosis of > 50% (Figure 1B). Due to concerns of possible residual ischemia in the setting of left ventricular dysfunction, risk of restenosis and subacute stent thrombosis, consideration was given to coronary artery bypass graft surgery.
       Post-stent deployment debulking of the underlying lesion with RA was also considered, as this had the potential to uncap the lesion, allowing repeat high-pressure balloon inflation for complete stent expansion. The patient gave written informed consent to proceed with this approach, which was carried out with surgical standby on the following day. A 9 Fr EBU 4.0 guiding catheter (Boston Scientific) was used to engage the left main coronary artery, and the previously placed stents in the LAD were crossed with a Rotafloppy wire (Boston Scientific). RA was then sequentially performed with 2.0, 2.25 and 2.38 burrs at 140,000–150,000 rpm for a total of 7 runs of 15–20 seconds each at the site of the proximal LAD under-deployed stent (Figure 1C).
       Following RA, during which no decelerations were noted, a 3.5 x 15 mm NC Ranger balloon was utilized to expand the stent at 18 atm. A 3.5 x 13 mm Zeta stent (Guidant, Corporation, Santa Clara, California) was then deployed at this site with final angiography demonstrating a < 10% residual stenosis

Figure 1b

(B) Proximal LAD stent site with the underlying lesion failing to yield to high-pressure balloon dilatation (arrow). RAO cranial projection.

Figure 1d

(D) Proximal LAD lesion after rotational atherectomy and additional stenting. RAO cranial projection. (E) Six-month intravascular ultrasound at the site of the proximal LAD stent, demonstrating the absence of in-stent restenosis and two layers of stents.

(Figure 1D) and TIMI-3 flow. Direct stenting of the PDA was also performed. No complications were associated with the procedure, and the patient was discharged home the following day. At 6 months, he remained asymptomatic, but an exercise sestamibi revealed possible ischemia in the anterior wall. Therefore, coronary angiography and intravascular ultrasound (Figure 1E) of the LAD were performed, which revealed no evidence of in-stent restenosis.
       2) Treatment of ostial lesions in cardiac transplant patients with adjunctive oral sirolimus. A 60-year-old man underwent routine annual cardiac catheterization 7 years after cardiac transplantation, which revealed a 75% mid-LAD stenosis and a 90% ostial ramus intermedius stenosis (Figure 2A). A 3.0 x 18 mm Cypher drug-eluting stent (Cordis Corporation, Miami,

Figure 1e

(E) Six-month intravascular ultrasound at the site of the proximal LAD stent, demonstrating the absence of in-stent restenosis and two layers of stents.

Florida) was placed in the mid-LAD, reducing the 75% stenosis to 0%. Due to the close proximity of the ramus intermedius lesion to the left main trunk, RA was performed with a 1.75 mm burr at 150,000–160,000 rpm for 5 runs of 10–15 seconds each. Adjunctive balloon angioplasty was performed with a 3.0 x 20 mm CrossSail balloon (Guidant), with a final residual stenosis of 10%. The patient was previously being treated with systemic sirolimus immunosuppression therapy after cardiac transplantation, and this was continued. Six-month post-PCI angiography confirmed the absence of restenosis (10% angiographic stenosis; Figure 2B) at this ostial ramus intermedius lesion.
       3) Treatment of common femoral and ostial superficial femoral artery lesions. A 65-year-old man was referred for lower extremity angiography for lifestyle-limiting claudication affecting his right leg (ankle brachial index of 0.65). Diagnostic angiography, performed by obtaining access in the left common femoral artery, revealed a heavily calcified 90% stenosis in the right external iliac artery and a 90% stenosis in the ostial right superficial femoral artery (Figure 3A, B). An elective surgical option was not entertained due to the patient’s preference, and percutaneous revascularization was performed. Utilizing the contralateral approach, a 5.0 x 20 mm Agiletrack balloon (Guidant) was used to attempt predilatation of the lesion in the right external iliac artery, but was unsuccessful due to severe calcification. RA was sequentially performed with 2.0, 2.25 and 2.5 mm burrs at 150,000 rpm in the right external iliac artery and ostial right superficial femoral artery. Adjunctive balloon

Figure 2a

(A) Ostial ramus intermedius stenosis of 90% in a cardiac transplant patient. Anteroposterior caudal projection.

angioplasty in the ostial right superficial femoral artery was now feasible and resulted in a residual stenosis of 30%. Stent placement in the right external iliac artery with a self-expanding 8.0 x 38 mm Dynalink stent (Guidant) resulted in a residual stenosis of 10%. Post-procedural and 6-month Duplex examination revealed an ankle brachial index of 0.9, with minimal residual symptoms of claudication.

Discussion
       In this report, we describe three expanded applications of rotational atherectomy. Each of these cases is unique in that they allowed short-term performance and long-term success of percutaneous revascularization in lesions that would have otherwise required coronary or peripheral artery bypass surgery. The unmatched ability of this device to ablate calcific and fibrotic lesions allows continued expansion of coronary and peripheral interventional therapies.
       During treatment of heavily calcified coronary lesions with RA, lesion modification primarily through debulking, enables easier stent delivery and expansion.6 Prior to the widespread utilization of direct stenting, balloon

Figure 2b

(B) Six-month coronary angiography revealing the absence of restenosis at the ostial ramus intermedius lesion treated with rotational atherectomy and adjunctive oral sirolimus. Anteroposterior caudal projection.

predilatation was routinely performed and recommended to ensure that stent expansion at the time of deployment would not be hampered. However, balloon predilatation leads to increased injury with resultant dissections, “geographic miss” during stent implantation in matching the stent to the balloon-injured area, longer procedural times, and higher fluoroscopy exposure without any associated clinical benefit.^7,8 In non-calcified, non-tortuous and non-angulated lesions, direct stenting has proven safe and cost-effective with equivalent clinical results.⁹ In cases of poor stent expansion, high-pressure balloon dilatation with non-compliant balloons usually enables complete stent expansion. However, in the rare case of incomplete stent expansion, the risk of restenosis is not only higher due to lower acute gain, but also puts the patient at risk for subacute stent thrombosis.¹⁰ In such patients, treatment options are limited, and often coronary artery bypass graft surgery is required.
       We describe the successful percutaneous treatment of a patient who had a residual stenosis of > 50% after stent deployment in the proximal LAD that failed to yield despite high-pressure inflation with a non-compliant balloon. Though the Cutting Balloon (Boston Scientific)¹¹ and rotational atherectomy¹² have been used to enable stent expansion in restenotic and calcified lesions months after the index procedure, the approach we present, as also utilized by Medina et al,¹³ is one to consider at the time of the initial stent placement for a grossly under-expanded stent. It requires choosing a relatively large rotational atherectomy burr (2.00–2.50 mm) based on the residual lumen after direct stenting, followed by high-pressure, non-compliant balloon dilatation. The goal of this approach is to uncap the underlying lesion, enabling optimal stent expansion. To minimize the potential for metal particle embolization and stent strut disruption in a freshly deployed stent, we recommend short burr runs (10–15 seconds each) of 140,000–150,000 rpm with this approach. The procedure should also be completed by an additional final stent deployment at the site of atherectomy, as optimal stent expansion is imperative for the prevention of subacute stent thrombosis and lowering restenosis. Furthermore, although surgical standby is rarely required in the current era of percutaneous revascularization, we feel that this approach warrants a surgical room and team on standby.
       Cardiac transplant vasculopathy is a major cause of mortality after heart transplantation. Though many agents have been studied to prevent the development of this disease after transplantation, most have been unsuccessful.¹⁴ Neointimal hyperplasia is felt to be the underlying pathophysiology for this disease, and the antiproliferative agent

Figure 3a

(A) Right external iliac artery with multiple calcified stenotic lesions and a cross-over sheath from the left femoral artery in place. Left anterior oblique projection.

Figure 3b

(B) Right superficial femoral artery (medial vessel) with a calcified ostial stenosis and rotational atherectomy burr. Left anterior oblique caudal projection.

sirolimus was recently utilized successfully in reducing cardiovascular events in cardiac transplant patients.¹⁵ We report the successful use of RA in an ostial ramus intermedius lesion in a cardiac transplant patient treated with adjunctive sirolimus, who had no evidence of restenosis at 6-month angiography after index PCI. Rotational atherectomy followed by balloon angioplasty led to the successful treatment of an ostial ramus intermedius lesion that originated from the left main coronary artery, and adjunctive sirolimus may have helped in blunting a neointimal proliferative response. Though we do not advocate avoiding drug-eluting stents in cardiac transplant patients, anatomically challenging lesions such as ostial stenoses that are known to have high restenosis rates and have difficulty in stent positioning could be treated in this manner.
       Though RA has been successfully used in peripheral vascular interventions,¹⁶ enthusiasm for using this device has waned due to an unacceptably high rate of restenosis in peripheral vessels. However, the common femoral artery and ostial superficial femoral artery represent a difficult anatomical situation due to their location at the hip joint. In this flexion area, stenting is generally not recommended, and balloon angioplasty alone has a high risk of dissection and elastic recoil. Adjunctive RA, as described here, enabled a successful result with resolution of symptoms and avoidance of the need for stenting. RA is frequently used in ostial coronary lesions,¹⁷ but it is not well-established as a tool for use in the peripheral vasculature for ostial lesions. Furthermore, it can also enable treatment of the common femoral artery in patients who are poor candidates for surgical revascularization by choice or due to comorbid medical conditions.
       Although prior data revealed that rotational atherectomy was utilized in 3–5% of patients undergoing PCI,^3,4 in our current coronary and peripheral interventional practice, with the availability of cutting balloon atherotomy, drug-eluting stents and decrease in brachytherapy, the utilization of rotational atherectomy is even lower at 2.1% of all PCI and peripheral interventional procedures. Novel uses of rotational atherectomy include debulking after failure of stent expansion, treatment of ostial or non-stentable lesions in cardiac transplant patients (with adjunctive oral sirolimus), and treatment of calcified/fibrotic lesions in the peripheral vasculature, especially in vessels that are suboptimal for stenting.

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