Journal of Invasive Cardiology

David Auth first described rotational ablation in 1986 as a technique for winding up coronary thrombus at low rotational speeds, thus capturing it on the rotating burr and shaft. In addition, he believed it decreased the force required to penetrate organized thrombus.¹ The technique was fine-tuned, becoming high-speed rotational atherectomy, and was presented as a novel modality to create a uniform lumen with less barotrauma to the artery in the hope of reducing restenosis.² Much has happened in interventional cardiology since Auth introduced the Rotablator^® (Boston Scientific Corp., Natick, Massachusetts), and the report of Benezet and colleagues in this issue of the Journal is a testament to just how much time has gone by.³ This consecutive series of 102 patients with severely calcified coronary lesions treated at a single institution over a 4-year period with rotational atherectomy followed by drug-eluting stent (DES) implantation showed a 99% angiographic success rate, with a low dissection rate, no perforations and no procedural deaths. These patients had severe angiographic coronary artery disease: 46.1% had three-vessel disease, 68.6% had type C lesions and the average implanted stent length was 39.3 mm. 12.7% of patients had lesions treated in the left main coronary artery. The patients were clinically high-risk as well, with half the group over the age of 70, a 53% rate of diabetes and a 13% incidence of chronic renal failure. Despite the odds stacked against them, the outcomes were acceptable. The clinical success rate was 97.1%, with an in-hospital major adverse cardiac event (MACE) rate of 2.9%. The 30-day event rate was also as might be expected for this group, with 3 (2.9%) deaths and 5 (4.8%) stent thromboses (3 definite and 2 probable). Late outcomes were also commensurate with expectations. At a median follow up of 15 months, there were 2 more deaths for an overall mortality rate of 4.9%, no further stent thromboses, a 3.9% rate of myocardial infarction and an 8.8% target lesion revascularization rate. It should be noted that the authors used the smallest burr judged necessary to modify the plaque and facilitate stent delivery, with an average burr size of 1.5 mm and a burr/artery ratio of 0.56. This is in line with current concepts of plaque modification rather than maximal debulking. They also used intravascular ultrasound guidance for the stent post-dilatation if residual stenosis after initial stent deployment was ≥ 20%. High-pressure postdilatation was utilized in two-thirds of the patients and glycoprotein IIb-IIIa inhibitor in 30%. Pretreatment with 300 mg of clopidogrel and aspirin 100–300 mg was performed, and the dual antiplatelet agents were to be continued for 12 months. The authors review previous studies of rotastenting with bare-metal stents and DES, make the point that the results of their single-center study are in line with or better than previous results, and admit the limitations of any observational or post-hoc analysis.