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RCA CTO with rotablation
Andrzej Ochała
Medical University of Silesia in Katowice
Non-CTO Specific Tools (but used much more commonly in CTO PCI)
• Guideliner
• Snares
• Laser
• Perforation gear
• Rotablator
Clinical Application: Rotablator in Calcification
Calcium is Common
The prevalence of severe calcium, defined as superficial in nature with greater than 180° arc.
Angio assessed 12% of PCI cases
IVUS assessed 26% of cases.1
Calcium can preclude optimal stenting.
Asymmetrical stent expansion occurs in up to 50% of cases where calcium is not treated before stentdeployment.2
DES, rotational atherectomy is an important tool for calcified lesions
Lesion preparation with compliance change for a calcified lesion can substantially facilitate stent delivery andsymmetrical stent expansion for more homogeneous drug delivery.3
1. Mintz et al. Patterns of Calcification in Coronary Artery Disease. Circulation April 1995, Volume 91, No 7
2. Moussa, Moses, Columbo et al. Coronary Stenting After Rotational Atherectomy in Calcified and Complex Lesions. Circulation 1997; 96:128-136
3. Iakovou, I. et. al. J Am Coll Cardiol 2005;46:1446-55
• Probably Should
• Definitely Should
• Definitely Should Have
– “I wish I wouldn’t have done that” category
Rotablator
Rotablator Indications
Should
•
•
•
•
•
Calcification
Diffuse disease
Bifurcation Debulking
CTO- Deliver gear
Lesion Preparation
Should Have
• Goal is to not operate inthis space.
Prior to use, please see the complete ‘Directions For Use’ for more information on Indications, Contraindications, Warnings, Precautions, Adverse Events and Operator’s Instructions.
Rotablation : Precautions, ContraindicationsPrecautions
• Ejection fraction less than 30%
• Lesions longer than 25mm
• Angulated lesions
• Recommend temporary pacemaker in the RCA and dominant Cx
• Rotablator System use should only be carried out at hospitals where
emergency bypass surgery can be immediately performed in the event
of a potentially injurious or life threatening complication.
Contraindications• Saphenous Vein Grafts
• Last Remaining Vessel
• Thrombus
• Significant Dissection
• Non-surgical candidates
Rotational Atherectomy Complications
Eftychiou et al TCT 2014
N= 518
Console DynaGlide™ foot pedal
Hardware
Rotawire™ Floppy Guide Wire
• Flexible and torqueable to enhance navigation
• Significantly reduced guidewire bias
• Short Spring Tip (2.2 cm)
• Light rail support
330 cm total length
Rotawire™ Extra Support Guide Wire
• Spring Tip (2.6 cm)
• Lead wire for those physicians requiring a “stiffer” wire
330 cm total length
• 65 years old male
• Unstable angina CCS III
• Hypertension
• Hyperlipidemia
• Diabetes Mellitus
Case presentation
Laboratory results:
• Hb=11.90 g/dl, L=3.54 103/ul, E=3.91 106/ul, Ht=34.90%
• Creatinine = 0.79 md/dl, GFR>60ml/min/1.73m2
• TCH=149 mg/dl; LDL=88 mg/dl; HDL=35 mg/dl; TG=129 mg/dl
Case presentation
Electrocardiogram:
• LVEF=50%, hypokinesia inferior wall.
• Atrial fibrilation, HR 70-80/min.
Medications:
• aspirin, clopidogrel, bisoprolol, digoxine, perindopril, VKA, rosuvastatin, pantoprazole.
Case presentation
Echocardiography:
Basal Angiography (bilateral injection)
Dual arterial access with EBU 7Fr left femoral and JR4 8Fr right femoral
CTO ballon NC nano 0.85x10mm failed to cross CTOWire - ASAHI Filder XT-A
Procedure
Predilatation of proximal segmentBallon Apex 3.0x20mm
Procedure
Guideliner 6Fr Corsair (unsucceful corssing)
Change wire for rotawire
Procedure
Dissection type E after rotablation(1.25mm burr size)
Contrast volume = 250 ml
DES Synergy (Everolimus) 2.5x24mm
DES Synergy (Everolimus) 3.0x32mm
DES Synergy (Everolimus) 3.5x32mm
DES Resolute (Zotarolimus) 3.5x18mm
Final result
Conclusions
• Many CTO cases are done today in highly calcified lesions.
• Succesful passage with guide wire in CTO in not the success of procedure.
• Rotablation is very useful in calcified CTO lesions cases.
• Rotablation in CTO cases will definitely increased in numbers in the nearest future.
