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Questions / Answers from October 20, 2009 Case

Questions / Answers

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Why has there been a disparity in the use of RA – much more at your institution than elsewhere?
There is a steep learning curve in performance of rotational atherectomy and to maintain the skills you need to keep doing 5-10 cases per month. RA is indicated for heavily calcified lesions only and hence it's use is limited. Overall approx 2% of the
PCIs in USA involves RA (about 20,000 cases). At Sinai overall use of RA is about 6-7% (40-50 cases per month). High RA number at Sinai, is the result of our reputation of safely performing RA in the Tristate area and pts are selectively being referred for it.
What are the reasons RA has not been adopted more?
Largely because of perception of the complex device set up, flimsy 0.009" Rota guide  wire and potential complications (if not done properly)
We find the RA guide wire a “pain”.  What are your comments?
I agree with it. In my opinion thin and flimsy Rota guide wire is difficult to negotiate  in the vessel. If Rota guide wire becomes 0.014", I predict RA volume will double or even triple overnight.
What are some techniques to prevent wire bias?
Take the tension out of the bur, use small wire and in some cases bend the wire at the site of wire bias. Still wire bias may occur and as long as you do not loose the wire position, it's ok and may even work to our advantage as usually causes bigger lumen gain.
How do you determine the appropriate sizing of the RA burrs?
Rough principle is to have Burr: artery ratio to 0.4-0.5. That usually means 1.5mm Burr  in about 50%, 1.75mm Burr in 40% and rarely 2.0mm Burr. Also 1.25mm burr is used when no distal vessel is seen or 1.5mm balloon can't cross the lesion. Some angulated lesions also, will need only 1.25mm Burr and with the favorable wire bias, lumen gain post RA may be sufficient followed by PTCA and stenting.
How often do you need pacing for RA?
Only during dominant RCA or LCx and unprotected LM also.
Are there situations where despite the presence of heavy calcification, you will not use RA?
If RA wire crossed, then RA is the only device in these heavily calcified lesions, to successfully complete the PCI. Therefore, if there is no dissection, then RA will be indicated. Hence no situation of not using the RA in heavily calcified lesions even if there is extreme tortuosity (use 1.25mm burr in these cases).
How often are you using IVUS to assist your RA procedure?  Is it mainly for sizing of stents?
We don't use IVUS to decide for the need of RA. Decision of RA is made only by angiogramand use it in heavily calcified (persistent densities during entire cardiac cycle before contrast injection or tram-track calcification on both vessel walls). IVUS in our cath lab, is used in about 25% of DES cases, to ensure full DES expansion and rarely is used to size the stent.
What are the important reasons for your success with RA?  Is it mainly proper case selection?
Reason for RA success are close attention to techniques, B:A ratio about 0.5 and frequent but indicated use of the technique.
What is your strategy for wiring RA lesions?  Do you always cross with the Rota wire?
In simple and moderate tortuosity, directly use the Rota wire and in tortuous and angulated lesions, use your 'workhorse' wire with the over the wire balloon (or transit catheter) and then change to Rota wire.
 In this procedure with planned RA of the diagonal branch, can you ablate with the two guide wires in place?
NO. You can't leave another wire in the vessel while doing RA as Rota burr will cut the wire.
Have you had success with RA for in stent restenosis?
RA is indicated for in-stent restenosis only if balloon can't cross or their are multiple branches which you need to protect during PCI as RA will cause less plaque shift and side branch occlusion.
What is the role of Angiosculpt or cutting balloon in calcified cases?
Both these 'atherotomy' devices can work in mild to moderate calcified lesions but not in heavily calcified lesions where RA is clearly indicated. Many time these devices can be used post RA to improve lumen gain post RA before stenting.
Can second generation DES (XienceV, Promus or Endeavor) provide good radial strength for ostial lesions?
In non-aorto ostial lesions, XienceV/Promus works well after cutting balloon but in LM ostium, they do not provide good radial strength and hence Cypher still remains the work horse DES for ostial LM lesions at Sinai (sometimes used inside the XienceV DES at LM ostium).

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