Discussion
The management of heavily calcified coronary lesions (HCCL) presents as a significant clinical challenge for interventional cardiologists. To begin with, the geometry and rigidity of these calcified lesions make optimal device delivery and deployment difficult.[2] Furthermore, balloon dilatation of heavily calcified stenosis might also increase the risk of dissection or perforation. [3]
As a result, various devices and techniques have been developed to address these clinically relevant challenges. One such advancement is rotational atherectomy, in which a portion of the fibrous, calcified, inelastic plaque is crushed by using a rotating brass burr mounted on a flexible drive shaft and coated with diamond chips, thereby modifying the plaque compliance. This results in a smooth, non-endothelialized surface with intact media. [4, 5] Because of differential cutting, healthy vessel segments proximal and distal to the lesions remain unaffected. Following a successful rotational atherectomy, an open path is left for subsequent balloon angioplasty or stenting of the initial lesion. [6]
Though CABG is still the class I indication for unprotected left main coronary artery (LMCA) disease in current PCI guidelines, increasingly favourable PCI clinical results highlight the fact that PCI for unprotected left main has been upgraded to a class IIa or IIb alternative to CABG in anatomically suitable patients or those at a higher risk for surgical adverse events. [7,8] In actual practice, conservative thinking and local traditions usually prevent elderly patients with complex LM lesions from undergoing open heart surgery. On the other hand, well-performed PCI was associated with short procedure time, short duration of hospitalization, and faster recovery, which are very important in high risk patients, whereas bypass surgery in elderly patients with multiple co-morbidities could be associated with very high surgical risk. [9, 10]
In the drug-eluting stent (DES) era, the resurgence of rotational atherectomy (RA) particularly for very complex heavily calcified lesions, [11, 12], highlights the importance of plaque modifications before DES can be successfully deployed to exert the expected effects. The most common risks are acute no flow, severe vessel dissection with impending acute closure, athero-embolism, and transient profound hypotension. [13] Many coronary interventionists are intimidated by rota-ablation for these reasons. However, it is critical to anticipate and prevent these events while also dealing with them appropriately once they occur. On the other hand, thrombus-laden vessels, vessels with existing advanced dissections, last remaining vessels and saphenous venous grafts have traditionally been considered contraindications to rota-ablation therapy.[14, 15]