**4. RotA complications**

Possible but rare complications include myocardial infarction, emergency CABG, coronary artery dissection, no reflow phenomenon, due to peripheral embolization, perforation or severe coronary artery spasm (Cavusoglu et al, 2004). The strict application of the general rules for the optimal use of RotA mentioned above, eliminates the possibility of any complication.

The lesion in Figure 6 had previously been treated unsuccessfully using direct balloon dilatation without rotational atherectomy of the calcified plaque. A. Attempt to deploy the balloon (white arrow). B. Incomplete deployment of proximal end of the balloon (open arrows). C. Rupture of the angioplasty balloon (thick black arrow). D. The result of the rupture

Other indications are ostial lesions with severe fibrosis with or without calcification, and

 In cases with multiple HCCL in the same vessel (tandem lesions) (Figure 8), segmental RotA is preferred. Because of the potential for a large quantity of plaque debris, a stepped burr approach is recommended. Interpolated low pressure balloon angioplasty may be helpful in improving flow, can also localize the areas of resistance and improve

 In ostial lesions (specifically in RCA) (figure 9) the frequent fibrocalcific characteristics of these lesions make them well suited for rotablation treatment. Coaxial placement of the guiding catheter is mandatory (assess in two projections-best RAO). Straight alignment of the guide catheter is essential in order to center the guidewire (extra support). The lie of the guidewire is essential and keeping the tip just beyond the lesion

 In bifurcation lesions the mainstay of treatment is branch preservation and adequate lumen in both limbs. Rotablation should be started at the most difficult to wire branch first. Use low burr-artery ratios (<0.5) especially when there is angulation present. In coronary arteries with severe tortuosity the main issue is to avoid perforation. Keeping the tip of the guidewire just beyond the lesion is essential in order to reduce sidewall tension. A stepped-burr approach and the use of undersized burrs are recommended. The activated burr should be advanced at low speed ensuring that there is no wire tension. Ablation of normal tissue can occur if the tension on the wall exceeds

 Failed PCI is either due to inability to cross the lesion or dilate. These lesions are frequently calcified. The decision to use rotablation should be made early, before large

 The inability to cross a CTO with a balloon catheter occurs in approximately 7% of all CTOs that are successfully crossed with a guidewire. RotA is a safe and effective technique to overcome this frustrating situation (Figure 11). Chronic total occlusions are well suited for rotational atherectomy and treatment is only limited by the ability to cross the lesion with the guidewire. Conventional guidewires should be used and exchange for the rota-wire with a OTW catheter. These lesions are frequently fibrocalcific.

Possible but rare complications include myocardial infarction, emergency CABG, coronary artery dissection, no reflow phenomenon, due to peripheral embolization, perforation or severe coronary artery spasm (Cavusoglu et al, 2004). The strict application of the general rules for the optimal use of RotA mentioned above, eliminates the possibility of any

Initiating treatment with the smallest burrs (1.25 mm) is the safest approach.

is the characteristic escape of contrast medium distal to the balloon (thin black arrow).

balloon-inaccessible lesions, provided that the Rotawire can cross the lesion.

vasospasm.

may improve the centering.

dissections appear.

**4. RotA complications** 

complication.

the elasticity of the vessel (wire bias) (Figure 10).

Fig. 8. Tandem calcified LAD lesion Tandem LAD lesions before, after Rota (segmental approach) and final result after DES.

#### Fig. 9. Calcified ostial RCA lesion

A. Calcified ostial lesion in the right coronary artery (black arrow). B. Restoration of vessel patency with the combination of rotational atherectomy and drug-eluting stent (white arrow).

Rotablation in the Drug Eluting Stent Era 189

 RotA followed by balloon angioplasty does not improve the rates of restenosis compared to direct balloon angioplasty, leading to high rates of restenosis and need for TLR—in up to 40% of cases (Reifart et al, 1997). RotA + balloon angioplasty strategy is better for the prevention of restenosis in small coronary vessels compared to balloon angioplasty alone (Mauri et al, 2003). BMS implantation after RotA has a high success rate, with an acceptable incidence of complications and a clearly lower incidence of angiographic restenosis compared to plain angioplasty, but the restenosis rate and need for TLR remain high, at

22.5% according to one previous study (Moussa et al, 1997).

Fig. 12. Complex LMS-LAD Rotablation with ECMO support

hemodynamic support of ECMO machine.

(A- B) heavily calcified ostial LMS stenosis (black arrow), elongated 95% LAD stenosis (black head arrows)- (in magnification on the right-down corner), metallic aortic valve (white head arrows) and a collateral artery from the LAD to the occluded RCA (white arrows), in a patient with poor LV and EF 20%. (C-D) Final angiographic result after rotablation and stent implantation (in magnification on the left- down corner) with the

**6. RotA in DES era** 

Fig. 10. Wire bias

Wire bias can occur in tortuous vessels, increasing the risk of perforation.
