Rotational Atherectomy Complications: Bailout and 8 Cases

Rotational atherectomy (rotablation) is a mainstay for opening heavily calcified and non-crossable coronary lesions, but its complications are specific: a burr that becomes stuck in the lesion, coronary perforation, and slow flow causing severe bradycardia. Safe practice rests on knowing its contraindications, sizing the burr carefully, having bailout strategies rehearsed and a cardiac surgical team available when rescue fails.

Dr. Subhash Chandra, Chairman - Interventional Cardiology - Cardiology & Structural Heart Disease, BLK-Max Super Speciality Hospital, New Delhi, India, illustrated these risks with cases from his own catheterisation laboratory, including the ones that went wrong. This article covers when rotablation is and is not appropriate, its complications and how to manage them, and the lessons from eight cases. The wider planning sequence is in the complete guide to calcific coronaries management; how to decide between rotablation, orbital atherectomy and intravascular lithotripsy is in the article on IVUS and OCT criteria for calcium modification.

When is rotational atherectomy indicated?

Rotablation is indicated for heavily calcified lesions that a balloon cannot cross or cannot dilate. A diamond-coated burr, spinning at very high speed over a dedicated guide wire, ablates hard calcium into microscopic particles while sparing the elastic, soft tissue of the vessel wall. Dr. Chandra regards angioplasty with rotational atherectomy as the best way to deal with heavily calcified lesions, and in his practice and experience it has emerged as the best tool for non-crossable lesions, where not even a microcatheter will pass.

A well-ablated lesion looks clean, without dissection and without slow flow, and accepts a stent easily. A lesion forced with a non-compliant balloon, by contrast, either does not yield or yields suddenly with extensive dissection.

Contraindications to rotational atherectomy

Certain lesions are relative contraindications to rotational atherectomy today. Dr. Chandra lists:

• Severely tortuous vessels.
• Lesions containing thrombus.
• Major dissections.
• Bypass grafts, particularly venous grafts.

Where none of these is present, he regards rotablation as the preferred approach to heavy calcium.

Rotational atherectomy complications and how to manage them

A stuck burr: bailout techniques

The most feared complication is a burr that becomes lodged in the lesion and cannot be withdrawn. The rotablation burr is front-loaded: it ablates as it advances, so once it has passed through a tight lesion it can become trapped behind it. A forceful pullout risks avulsing the artery.

Rescue strategies for a stuck burr are well defined in the literature, and Dr. Chandra lists them:

1. Passing a second, buddy guide wire alongside the burr.
2. Passing a buddy balloon to dilate around the burr.
3. Disengaging the stuck burr.
4. Cutting the drive shaft sheath behind the burr, advancing a mother-and-child (guide extension) catheter over it up to the burr, and pulling the burr out through it.

If these fail, the last resort is to send the patient for surgery.

Coronary perforation

Perforation is more likely in angulated or very tortuous vessels, which must always be examined carefully before ablation. Covered stents and pericardiocentesis equipment must be ready on the table whenever rotablation is planned.

Slow flow, bradycardia and temporary pacing

Ablated debris can cause slow flow, which in a dominant artery can produce extreme bradycardia or asystole. Temporary pacemakers are now largely not needed for rotablation of the left coronary system, where aminophylline or atropine is usually sufficient. For a large dominant right coronary artery, or a dominant circumflex artery, a temporary pacemaker should be placed beforehand.

Eight calcified PCI cases and their lessons

Dr. Chandra's eight cases cover complications and their bailout, and the combinations of tools that allowed stents to be delivered in the most difficult calcified lesions.

Case 1: perforation from an acute angle

A rotablation burr left the coronary tree because of an acute angle in the vessel. The angiogram showed the burr passing out of the artery, followed by a severe perforation. Because the lesion had not yet been dilated, neither a balloon nor a covered stent could be passed to seal it. The patient was moved immediately from the catheterisation laboratory to the operating theatre, and the patient's life was saved. Lesson: angulation is a warning sign for rotablation, and surgical backup must be immediately available.

Case 2: a stuck burr in the circumflex

An octogenarian with a cardiac resynchronisation therapy defibrillator (CRT-D), left ventricular dysfunction with viable myocardium, and angina had calcific lesions in both the left anterior descending (LAD) artery and the left circumflex artery. Rotablation of the LAD was followed by stenting. In the circumflex, a balloon could not open the heavily calcified lesion, so the same burr was used. It was probably oversized for the circumflex, and it became stuck. By switching the device to its low-speed mode and applying controlled traction on the burr together with the guiding catheter, the team withdrew it. Without that, the patient would have needed surgery. Lesson: size the burr to each vessel, not to the previous one.

Case 3: a shepherd's crook right coronary artery

A right coronary artery with a classic shepherd's crook origin was engaged with an Amplatz left 2 (AL2) guiding catheter, with a guide extension ready in case of difficulty. Rotablation of the calcium in the right coronary artery made the rest of the procedure straightforward, and the stent passed easily. Lesson: one should never start half-heartedly on a calcified lesion in the hope that a balloon will be enough.

Case 4: a non-crossable LAD

A guide wire crossed a calcified LAD lesion, but nothing else would: even the smallest balloons failed. The team exchanged the workhorse wire for a rotablation wire and used a 1.25 mm burr. The burr passed through the lesion where nothing else could, and long stents were placed in the distal and then the proximal LAD. Lesson: rotablation is the tool for lesions that nothing else will cross.

Case 5: rotablation, lithotripsy and a guide extension

A diabetic octogenarian had a heavily calcified LAD that not even a balloon could pass. Rotablation with a 1.5 mm burr was the first choice. A heavy calcific nodule at one point then required intravascular lithotripsy, with pulses delivered at several points along the calcium. Even after this combined rotatripsy, the stents would not advance, so a guide extension catheter was introduced, through which the stent passed and was deployed along the whole LAD, followed by post-dilatation. Lesson: the right combination of tools, not any single device, achieves the result in the most calcified arteries.

Case 6: a sharp left main and circumflex angle

A heavily calcified circumflex lesion with a very acute bend at the left main origin was approached with a 7 French extra-backup guiding catheter and an anchoring wire in the LAD. Anchoring wires and anchoring balloons add the push force needed to advance devices. Only an angulated microcatheter could deliver the guide wire. Imaging showed a previous stent and heavy proximal calcium, which was dilated with a non-compliant balloon. The stent still would not advance, so a 5 French mother-and-child catheter, longer than the guiding catheter and acting like a guide extension, was used to deliver it, and the procedure ended with left main to circumflex stenting.

For side branches with an awkward origin, Dr. Chandra shapes a hairpin bend on the guide wire to enter them. Wherever a side branch is in doubt, it should be secured before the main branch is treated, because losing a side branch in a bifurcation is a serious problem to be avoided at all costs.

Case 7: stent loss retrieved with a gastric snare

A patient with a vertical take-off of the right coronary artery and a chronic total occlusion of the mid and distal vessel was treated with a hockey stick guiding catheter and a guide extension parked deep in the artery. Chronic total occlusion wires crossed the occlusion, and balloons and stents passed easily through the guide extension. To stent the proximal segment, the guide extension had to be withdrawn, and in that process the stent came off its balloon. It hung half in the right coronary artery and half in the aorta.

Leaving it in place would close the right coronary artery; if it embolised, it could travel to the brain or elsewhere in the systemic circulation. A standard snare would not grip it, because snares work on the principle of capture in small-calibre vessels, not in a large aorta. Twisting it between two or three additional wires failed, and so did a coronary micro-snare. What saved the day was a large gastric snare kept in the laboratory for gastrointestinal work, which captured and withdrew the stent. The procedure was then repeated, and the new stent was telescoped into the distal stent. Lesson: retrieval equipment beyond the coronary inventory can be decisive.

Case 8: a left main bifurcation with napkin-ring calcium

In the final case, intravascular ultrasound showed very thick, napkin-ring calcium across the distal left main, proximal LAD and proximal circumflex, which only rotablation could treat. The circumflex was addressed first, then the LAD was stented after rotablation with a crossover from the left main. Because the circumflex took off at 90 degrees, the TAP technique (T-stenting and small protrusion) was used for the side branch, followed by a final proximal optimisation technique (POT), in which a short balloon reshapes the stent in the main vessel above the bifurcation.

Training, teamwork and the heart team

Rotablation has a steep learning curve and requires dedicated training and judgement to ensure safe outcomes. Dr. Chandra's cases show why: success depends as much on recognising when a lesion is unsuitable, and on rehearsed bailout, as on technical skill with the device.

When complications cannot be managed in the catheterisation laboratory, the patient goes to the cardiac surgeons. Interventional cardiologists, he points out, work through small punctures with wires and catheters; opening the chest is the surgical team's domain. Decisions are made by a heart team in which the cardiac surgeon, the interventional cardiologist and the anaesthetist decide together what is best for the patient.

Questions from doctors at the session, including how orbital atherectomy and rotablation differ in their risk of entrapment, are answered in the Live Discussion. For patients considering treatment, indicative ranges for angioplasty with stent are available, and Dr. Chandra's background is on his doctor profile.