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]