Mladen I. Vidovich, MD, FSCAI; Faisal Latif, MD, FSCAI

Introduction

None of us needs to be reminded that the complexity of a percutaneous coronary intervention (PCI) has increased and how rarely we encounter Type A lesions in daily practice. In a study, intravascular ultrasound (IVUS) revealed the presence of coronary calcification in 73 percent of target lesions. In contrast, the overall sensitivity of coronary angiography in detecting the presence of target lesion calcification was only 48 percent.1 Moderate or severe coronary artery calcium (CAC) is associated with increased target lesion failure, death, myocardial infarction (MI), and revascularization.2,3 Calcification also makes stent delivery challenging. Additionally, optimal stent expansion is difficult to achieve without vessel preparation. For all these reasons, optimal CAC lesion preparation has become the “sine qua non” of contemporary PCI. Both rotational atherectomy and orbital atherectomy have been extensively studied and provide similar outcomes.4 In this Tip of the Month, we provide practical considerations on choosing between these two techniques to ablate CAC for vessel preparation. Other modalities to treat CAC, such as laser atherectomy, scoring/cutting balloons, and intracoronary lithotripsy, will not be discussed.

 

Aspects to Consider When Choosing …

Rotational Atherectomy*

Orbital Atherectomy**

Comments

Guide size

Usually 6 Fr or larger; can use a 1.25 mm burr with a 5F guide

Typically 6 Fr 

Difficulty visualizing the vessel—with contrast injected through a 5 Fr guide while performing rotational atherectomy with a 1.25 mm burr—while feasible, poses a potential safety risk. Orbital atherectomy has the advantage of being able to treat larger diameter vessels using the high-speed feature without the need to upsize the guide catheter.

Arterial access

Radial or femoral

Radial or femoral

It is feasible with either arterial access site.

Ostial lesions

Ideal for severe aorto-ostial lesions

An ostial lesion that can be ablated “backward” (i.e., distal to proximal) if the crown can be advanced through the lesion

For ostial disease, rotational atherectomy offers more control and is probably the better choice, especially for tight and heavily calcified lesions.

Presence of a stent

Feasible and reported

Not recommended

There are alternative approaches that can be considered—laser or (in the future) intravascular lithotripsy. A guide extension can be used to protect the stent if atherectomy is needed distal to the stent.

Wire

Flimsy and hard to manipulate

Comparable to basic workhorse wires; a user-friendly wire tip

Newer orbital atherectomy wire technology offers advantages over the older design rotational atherectomy wire.

Bradycardia/need for pacing

Not uncommon in the right coronary artery (RCA)

Substantially less common

Intravenous aminophylline may prevent the need for temporary pacing with rotational atherectomy.5

Insertion/removal

Less cumbersome procedures as a result of the recently popularized single-operator technique of using Dynaglide™ to deliver and remove the burr6

Significant facilitation of crown delivery and allowance of single-operator use as a result of the new upgraded console with GlideAssist® feature7

Competition is good—both systems are becoming easier to use, which benefits everyone!

Vessel size

Excellent for severely stenotic/heavily calcified vessels

Superior debulking of larger vessels such as left main

This is possibly the most important difference between the two techniques. Orbital atherectomy creates more calcium modification in lesions with larger lumen area and produces noncalcified plaque modification. The devices are similar in lesions with smaller lumens.8

Tortuosity

“Tighter turns” can be easier to navigate by the burr

A crown that is better suited for “straighter segments”

This is an anecdotal observation and appears to translate well into practice and procedure planning. Note that neither is an absolute contraindication.

Cutting direction

Forward only

Forward and backward

This is an important feature to keep in mind. The Rotablator burr can get stuck since it does not cut backward. It should be kept spinning until withdrawn.

Equipment considerations

Nitrogen tank

No tank

With the latest generation Rotablator system, the tank is smaller and not as imposing.

Foot pedal

Phased out in the newer generation (Rota-Pro)

No foot pedal

New Rotablator systems do not have the foot pedal, so this will eventually become of historic interest only.

Lubricant allergies

RotaGlide™—contains egg-yolk phospholipids and olive oil

ViperSlide™ Lubricant— contains egg-yolk phospholipids and soybean oil

Allergies to eggs, olive oil, and soybeans must be checked before using these devices. While the use of RotaGlide™ is not mandatory, ViperSlide™ use is mandatory. Therefore, in a patient with prohibitive allergies, rotational atherectomy is the device of choice.

Bottom line

Both systems work well and have specific advantages and disadvantages. To maintain proficiency, the operator should use both technologies interchangeably as well as for niche applications.


*Rotational Atherectomy – Boston Scientific, Natick, MA, USA

**Orbital Atherectomy – Cardiovascular Systems, Inc., St. Paul, MN, USA

Summary

Atherectomy should be used to ablate moderate to severe calcification in coronary lesions prior to stenting. With the advent of newer atherectomy devices and platforms, the choice between rotational and orbital atherectomy for a particular lesion may be less clear. While both devices perform well and deliver similar outcomes, there are some practical pointers that help in choosing one device over the other.

References

  1. Mintz GS, Popma JJ, Pichard AD, et al. Patterns of calcification in coronary artery disease: A statistical analysis of intravascular ultrasound and coronary angiography in 1155 lesions. Circulation. 1995 Apr 1;91(7):1959-1965.
  2. Guedeney P, Claessen BE, Mehran R, et al. Coronary Calcification and Long-Term Outcomes According to Drug-Eluting Stent Generation. JACC: Cardiovasc Interv. 2020 Jun 22;13(12):1417-1428.
  3. Généreux P, Madhavan MV, Mintz GS, et al. Ischemic outcomes after coronary intervention of calcified vessels in acute coronary syndromes. Pooled analysis from the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) and ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) TRIALS. J Am Coll Cardiol. 2014 May 13;63(18):1845-1854.
  4. Goel S, Pasam RT, Chava S, et al. Orbital atherectomy versus rotational atherectomy: A systematic review and meta-analysis. Int J Cardiol. 2020 Mar 15;303:16-21.
  5. Megaly M, Sandoval Y, Lillyblad MP, et al. Aminophylline for Preventing Bradyarrhythmias During Orbital or Rotational Atherectomy of the Right Coronary Artery. J Invasive Cardiol. 2018 May;30(5):186-189.
  6. PCR Online. "How to use a Rotablator as a single operator." Published March 24, 2020, https://www.pcronline.com/Cases-resources-images/Zoom-on/My-Toolkit/2020/How-to-use-a-Rotablator-as-single-operator#:~:text=Principal%20idea.
  7. Lee MS, Nguyen H, Philipson D, et al. "Single-Operator" Technique for Advancing the Orbital Atherectomy Device. J Invasive Cardiol. 2017 Mar;29(3):92-95.
  8. Yamamoto MH, Maehara A, Galougahi KK, et al. Mechanisms of Orbital Versus Rotational Atherectomy Plaque Modification in Severely Calcified Lesions Assessed by Optical Coherence Tomography. JACC Cardiovasc Interv. 2017 Dec 26;10(24):2584-2586. 

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