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Rotational atherectomy to left circumflex ostial lesions: tips and tricks

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Abstract

Serious complications including vessel perforation may occur during rotational atherectomy (RA) to left circumflex (LCX) ostial lesions. In fact, if perforation occurs around LCX ostium, bailout procedures including deployment of covered stents may cause fatal ischemia in the territory of left anterior descending artery, which results in broad anterior acute myocardial infarction and subsequent death. In this review article, we described tips and tricks for RA to LCX ostial lesions. First, we should cautiously decide the indication for RA to LCX ostial lesions, because there are several reasons to avoid RA to LCX ostial lesions. Before procedures, we should estimate the difficulty of RA to LCX ostial lesions, which is mainly determined by the combination of the bifurcation angle and the severity of stenosis. Thus, the combination of the large bifurcation angle and the tight stenosis makes RA to LCX ostial lesions most difficult. Appropriate position of guide catheter and RotaWire is a key to successful RA to LCX ostial lesions. Differential cutting is an essential concept for RA to LCX ostial lesions. However, since there is no guarantee that differential cutting always works, small burr (≤ 1.5 mm) would be a safe choice as initial burr for RA to LCX ostial lesions.

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References

  1. Chipayo-Gonzales D, Hennessey B, Diz Diaz J, Salinas P. Transvascular balloon occlusion: a novel bailout strategy in large left main perforations. JACC Case reports. 2022;4(23): 101655.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Sakakura K, Ito Y, Shibata Y, Okamura A, Kashima Y, Nakamura S, et al. Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics: update 2023. Cardiovasc Interv Ther. 2023;38:141–62.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Jinnouchi H, Sakakura K, Taniguchi Y, Tsukui T, Watanabe Y, Yamamoto K, et al. Clinical outcomes and unique restenosis of calcified nodule in heavily calcified coronary artery. J Atheroscler Thromb. 2022;30:649–62.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Maron DJ, Hochman JS, Reynolds HR, Bangalore S, O’Brien SM, Boden WE, et al. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med. 2020;382(15):1395–407.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Yamamoto S, Sakakura K, Funayama H, Wada H, Fujita H, Momomura SI. Percutaneous coronary artery bypass for type 3 coronary perforation. JACC Cardiovasc Interv. 2015;8(10):1396–8.

    Article  PubMed  Google Scholar 

  6. Lai CH, Su CS, Wang CY, Lee WL. Heavily calcified plaques in acutely angulated coronary segment: high risk features of rotablation resulting in Rotawire transection and coronary perforation. Int J Cardiol. 2015;182:112–4.

    Article  PubMed  Google Scholar 

  7. Hiraya D, Sato A, Hoshi T, Ieda M. Life-threatening perforation of the left main coronary artery by a rotablator burr delivered on a broken rotawire. Eur Heart J. 2020;41(27):2600.

    Article  PubMed  Google Scholar 

  8. Foster-Smith K, Garratt KN, Holmes DR Jr. Guidewire transection during rotational coronary atherectomy due to guide catheter dislodgement and wire kinking. Cathet Cardiovasc Diagn. 1995;35(3):224–7.

    Article  CAS  PubMed  Google Scholar 

  9. Woodfield SL, Lopez A, Heuser RR. Fracture of coronary guidewire during rotational atherectomy with coronary perforation and tamponade. Cathet Cardiovasc Diagn. 1998;44(2):220–3.

    Article  CAS  PubMed  Google Scholar 

  10. Sakakura K, Taniguchi Y, Yamamoto K, Tsukui T, Jinnouchi H, Fujita H. Excessive rotational speed may be associated with the transection of guidewires in rotational atherectomy. Am J Cardiol. 2020;132:172–3.

    Article  PubMed  Google Scholar 

  11. Otsuka F, Sakakura K, Yahagi K, Joner M, Virmani R. Has our understanding of calcification in human coronary atherosclerosis progressed? Arterioscler Thromb Vasc Biol. 2014;34(4):724–36.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Sakakura K, Ito Y, Shibata Y, Okamura A, Kashima Y, Nakamura S, et al. Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics. Cardiovasc Interv Ther. 2021;36(1):1–18.

    Article  PubMed  Google Scholar 

  13. Nakazawa G, Yazdani SK, Finn AV, Vorpahl M, Kolodgie FD, Virmani R. Pathological findings at bifurcation lesions: the impact of flow distribution on atherosclerosis and arterial healing after stent implantation. J Am Coll Cardiol. 2010;55(16):1679–87.

    Article  PubMed  Google Scholar 

  14. Torii S, Sato Y, Otsuka F, Kolodgie FD, Jinnouchi H, Sakamoto A, et al. Eruptive calcified nodules as a potential mechanism of acute coronary thrombosis and sudden death. J Am Coll Cardiol. 2021;77(13):1599–611.

    Article  PubMed  Google Scholar 

  15. Tomey MI, Kini AS, Sharma SK. Current status of rotational atherectomy. JACC Cardiovasc Interv. 2014;7(4):345–53.

    Article  PubMed  Google Scholar 

  16. Gupta T, Weinreich M, Greenberg M, Colombo A, Latib A. Rotational atherectomy: a contemporary appraisal. Interv Cardiol (London, England). 2019;14(3):182–9.

    Article  Google Scholar 

  17. Sakakura K, Taniguchi Y, Yamamoto K, Wada H, Momomura SI, Fujita H. When a burr can not penetrate the calcified lesion, increasing burr size as well as decreasing burr size can be a solution in rotational atherectomy. Int Heart J. 2017;58(2):279–82.

    Article  PubMed  Google Scholar 

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Correspondence to Kenichi Sakakura.

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Conflict of interest

Dr. Sakakura has received speaking honoraria from Boston Scientific; he has served as a proctor for Rotablator for Boston Scientific; and he has served as a consultant for Boston Scientific. Dr. Jinnouchi has received speaking honoraria from Boston Scientific.

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Supplemental movie 1: Initial angiogram. (MP4 14512 KB)

Supplemental movie 2: The 1.5 x 10 mm balloon finally cross the lesion with power position of guide catheter. (MP4 37824 KB)

Supplemental movie 3: Angiography after 1.5 mm balloon dilatation showed better coronary flow. (MP4 13594 KB)

Supplemental movie 4: Before RA, we adjusted the guide catheter to make a coaxial position between the guide catheter and the LCX ostium. (MP4 6349 KB)

Supplemental movie 5: RA with the 1.5-mm burr. Although the 1.5-mm burr almost crossed the lesion after 7 sessions of RA, the back-up of guide catheter was not sufficient to have the 1.5-mm burr completely cross the lesion. (MP4 95419 KB)

Supplemental movie 6: We adjusted the guide catheter to strengthen the back-up force. (MP4 10097 KB)

Supplemental Movie 7: The 1.5-mm burr smoothly cross the whole lesion. (MP4 14630 KB)

Supplemental movie 8: After RA of the 1.5-mm burr, TIMI flow grade 3 was observed. (MP4 17506 KB)

Supplemental movie 9: An IVUS catheter crossed the lesion, and revealed successful differential cutting. (MP4 62637 KB)

Supplemental movie 10: After the burr 2.0-mm RA, an IVUS catheter revealed evidence of additional debulking. (MP4 72743 KB)

Supplemental movie 11: Final angiogram. (MP4 6531 KB)

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Taniguchi, Y., Sakakura, K., Jinnouchi, H. et al. Rotational atherectomy to left circumflex ostial lesions: tips and tricks. Cardiovasc Interv and Ther 38, 367–374 (2023). https://doi.org/10.1007/s12928-023-00941-y

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