How I deal with…and How I deal with…and what to avoid…what to avoid…

calcified diseasecalcified diseaseAdam de BelderAdam de Belder

Sussex Cardiac CentreSussex Cardiac CentreBrightonBrighton

ACI 2009ACI 2009

Declaration of interestsDeclaration of interests

I have received honoraria from I have received honoraria from Boston Scientific to help train Boston Scientific to help train cardiologists in rotational cardiologists in rotational atherectomy.atherectomy.

Very narrowed/CTOVery narrowed/CTO

FibrousFibrous

FibrocalcificFibrocalcific

Superficial calciumSuperficial calcium

Deep calciumDeep calcium

Principle of RA operationPrinciple of RA operation

Differential CuttingDifferential Cutting AllAll diseased plaque is inelastic diseased plaque is inelastic High speed rotational ablation High speed rotational ablation

differentiates healthy elastic vessel wall differentiates healthy elastic vessel wall from plaquefrom plaque

High speed rotational ablation High speed rotational ablation preferentially cuts preferentially cuts allall types of plaque types of plaque morphologymorphology

Principle of OperationPrinciple of Operation

Differential CuttingDifferential Cutting

Elastic tissue is able to deflect out of the way

Elastic tissue space

Elastic tissuedeflects

Direction of motion

Diamond crystal

Inelastic tissue is unable to deflect out of the way

Inelastic tissue space

Direction of motion

Diamond crystal

Forcefulmechanicalbreakdownof matter

post-PTCA procedure post-Rotablator® procedure

Case Case

63 journalist - NSTEMI63 journalist - NSTEMI

Small balloon

bigger balloon

Even bigger balloon

Another case…..

4 balloons, the final one of which was a quantum at 26 atm

CRIKEY….!!

Non-obstructive dissection – rotablation?

4 weeks later…..

Final result

Calcification – what to avoidCalcification – what to avoid

Do not use oversized balloons in Do not use oversized balloons in native coronary arteries and inflate native coronary arteries and inflate them to very high atmospheres in them to very high atmospheres in order to ‘crack the lesion’…order to ‘crack the lesion’…

If a case needs to be treated by If a case needs to be treated by rotablation , decide at an early stage rotablation , decide at an early stage with conventional PCI and stop the with conventional PCI and stop the casecase

Calcification – what to avoidCalcification – what to avoid

Inexperienced users have the highest Inexperienced users have the highest complication rates - do not use rotablation complication rates - do not use rotablation occasionally – buddy up with an occasionally – buddy up with an experienced colleague or pass the case on experienced colleague or pass the case on to a regular user of the technologyto a regular user of the technology

……sometimes, you have to swallow your sometimes, you have to swallow your pride and accept that there are some pride and accept that there are some cases that balloons and stents can’t treatcases that balloons and stents can’t treat

Rotablation experience – Sussex Rotablation experience – Sussex Cardiac CentreCardiac Centre

N =222N =222 70% >70yrs, 25%>80yrs70% >70yrs, 25%>80yrs Hypertension – 84%Hypertension – 84% Failure to cross or poor result – 6.7%Failure to cross or poor result – 6.7% Successful result – 93.3%Successful result – 93.3% Complications – death n=2, QWMI Complications – death n=2, QWMI

n=1, dissection n=4, perforation n=1, dissection n=4, perforation n=3, tamponade n=1n=3, tamponade n=1

Case – understanding calciumCase – understanding calcium

55 yrs55 yrs Stable anginaStable angina Prox LADProx LAD Previous pci severe dog-boningPrevious pci severe dog-boning

Once you are confident with what can be Once you are confident with what can be achieved with RA, higher risk cases can be achieved with RA, higher risk cases can be

undertakenundertaken 87 yrs87 yrs Hb 9Hb 9 Creat 400Creat 400 Too high risk for surgeryToo high risk for surgery Intractable anginaIntractable angina

ConclusionsConclusions Understand the nature of the heavily calcified Understand the nature of the heavily calcified

coronary arterycoronary artery Understand the limitations and potential harm Understand the limitations and potential harm

POBA and stenting can doPOBA and stenting can do Do some IVUS and see what you’re dealing withDo some IVUS and see what you’re dealing with Learn/refresh how to rotablate with a proctorLearn/refresh how to rotablate with a proctor Rotablation is not without risk – understand Rotablation is not without risk – understand

potential complications and how to avoid thempotential complications and how to avoid them Frequent users have better results and are more Frequent users have better results and are more

confident with its capabilityconfident with its capability If you think the case requires a rotablation If you think the case requires a rotablation

facility, then it probably does..facility, then it probably does.. ..perhaps the laser?..perhaps the laser?