**3. RotA Indications and technique according to lesion specification**

The absolute indication for RotA is the heavily calcified lesions (HCCL), localized or extended, and mainly the presence of a circumferential calcium ring where the lesion is undilatable by balloon angioplasty (Figures 6 and 7).

1. It is essential to use specific guiding catheters with sufficient support and coaxial

2. The atherectomy speed must be approximately 140000 rpm, although there is no clear

3. The intermittent application of RotA within lesion is preferred; usually "pecking" technique is used, where the burr is moved forward and backward the lesion, without

4. Starting with smaller burrs reduces the plaque burden to the distal bed and a patent

5. A RotA technique with 2 burrs may be chosen in order to reduce the incidence of the no-reflow phenomenon. The smaller burr (usually 1.25 mm) is used first, followed by a larger burr based on the size of the vessel, aiming at a burr/vessel ratio that does not

6. Bigger burrs may debulk more of the lesion but they also may damage/activate more

7. In cases of extensive rotablation and large amount of debulking, glycoprotein IIb/IIIa

8. The duration of RotA application should not exceed 15-20 sec, with immediate cessation

9. During RotA, 500 ml of heparinised (5000 units) normal saline solution with 5 mg verapamil and 1000 μg nitroglycerine is administered locally, with a view to preventing thrombus formation and vascular spasm, and avoiding the no-reflow

The concept of differential atherectomy: the rotablation preferentially ablates inelastic,

The absolute indication for RotA is the heavily calcified lesions (HCCL), localized or extended, and mainly the presence of a circumferential calcium ring where the lesion is

**3. RotA Indications and technique according to lesion specification** 

exceed 0.6-0.7. However sometimes a single small burr is sufficient

fitting.

blood cells

phenomenon.

Fig. 5. Differential atherectomy

calcified, atherosclerotic tissue.

undilatable by balloon angioplasty (Figures 6 and 7).

inhibitors is recommended.

if the revolutions drop by >5000 rpm

cut-off and some operators use 150,000 rpm.

lumen is achieved in a shorter period of time

pushing the rotablator into the lesion

Fig. 6. Longitudinal calcified LAD lesion

A. Localised calcified longitudinal lesion of the left anterior descending artery before the origin of the first diagonal branch (black arrow).

B. Restoration of vessel patency with the combination of rotational atherectomy and drugeluting stent (white arrow).

Fig. 7. Unsucessful treatment of calcified LAD lesion with POBA

Rotablation in the Drug Eluting Stent Era 187

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

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).

Fig. 8. Tandem calcified LAD lesion

Fig. 9. Calcified ostial RCA lesion

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

Other indications are ostial lesions with severe fibrosis with or without calcification, and balloon-inaccessible lesions, provided that the Rotawire can cross the lesion.

