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Coronary Angioplasty and Rotablation

Background

In 1929, the first catheterization of a human heart took place in Eberswalde, in the Federal State of Brandenburg, and was performed by Werner Forssmann, a German urologist. At that time, and for many years to come, the procedure was limited to investigations involving the right side of the heart. During the 1950s, and after undergoing further developments, the technique finally allowed access to be extended to the left side of the heart. In 1959, Mason Sones performed the first catheterization procedure involving contrast agents, which allowed selective visualization of the coronary arteries using x-ray technology. Over the course of the next few years, cardiac catheterization was mainly used for diagnostic purposes. It was not until the early 1970s that Andreas Grüntzig discovered that balloon catheters could be used in the treatment of stenotic blood vessels. After managing to reduce the size of the balloon catheters used, Grüntzig performed the first-ever balloon angioplasty procedure on a coronary artery in 1977. Before the advent of stents the effectiveness of the angioplasty procedure was limited by the vessel’s elastic recoil and its tendency to dissect. Ever since the introduction of stents, which allow a controlled over-expansion of the affected blood vessel, elastic recoil and dissection of artery have been successfully circumvented. If coronary artery stenosis is accompanied by large amounts of calcified deposits building up inside the vessel walls, treatment with routine angioplasty with balloons and stents may not succeed and these patients may need to go for CABG. Now the treatment is made easier and less risky if these calcified deposits are first modified or removed using a tiny and highly sophisticated drill, powered by compressed air. This is called rotablation. It is usually followed by balloon angioplasty, and the implantation of one or more stents.

What conditions are treated with Rotablation?

Nowadays, rotablation is used in cases with stenosis so severe that it can only be crossed with a wire, not a balloon, and in cases with calcifications so severe that they prevent a balloon from being inflated, even at high pressures. Rotablation can make treatment possible, or at least easier, in cases where imaging technology reveals severe calcifications. A special guide wire, which is required for the drill, is advanced past the site of stenosis. After a trial run outside the body, the drill, which is powered by compressed air, is advanced through the site of stenosis at a speed of 140,000-160,000 rpm. The process of drilling through plaque and calcified deposits inside the site of stenosis generates tiny fragments of debris, which can easily pass through the blood vessels and are finally excreted by the body. Once the drill head has been retracted, the site is widened using balloon angioplasty as per standard PTCA procedures. This step is usually followed by the implantation of drug-eluting stents, which ensure that treatment results remain satisfactory over the long term. In many cases, high pressure balloons are used to ensure that the stents are fully expanded. By using a drill that removes calcified deposits, the operator can ensure that the stent does not get caught in calcified deposits, and is not prevented from being advanced into the target zone. Rotablation is not suitable in cases where balloon angioplasty has resulted in tears to the vessel walls, where there is evidence of blood clots, or where there is a high degree of vessel tortuosity. As a heart attack is usually associated with blood clotting inside the blood vessels, rotablation is not usually suitable for use in patients with acute heart attack.

What happens during rotablation for coronary artery stenosis?

  1. Following the application of a local anesthetic, a tiny incision is made in an artery.
  2. A guide wire is used to introduce a sheath into the artery.
  3. A catheter is introduced and advanced to the coronary artery.
  4. The guide wire is used to cross the stenosis inside the coronary artery.
  5. The drill head is used to remove plaque deposits.
  6. The guide wire is used to advance a balloon and/or a stent to the site of the stenosis.
  7. The balloon is inflated and / or the stent expanded.
  8. Balloon and catheter are removed. A pressure bandage may be applied to the entry site, or it may be closed using a wound closure system.
  9. The patient is usually kept under observation for a duration of 48 hours.

How long is the recovery after a rotational atherectomy?

Patients can walk about six hours after a transradial procedure. Most patients spend the night in the hospital, return home after about two days, and go back to work after a week. Patients are advised to avoid heavy exercise for a month. They have to take blood-thinning medication for the rest of their lives. In about 20 percent of patients, the opened artery may narrow again within six months of the procedure. These patients may need another angioplasty, or coronary artery bypass surgery.

What are the risks associated with Rotational Atherectomy?

  • Bleeding around the heart
  • Injury to artery
  • Tearing of artery
  • Heart attack
  • Emergency bypass
  • Unsuccessful surgery: catheter cannot be advanced to blockage because of severe calcium deposits and bends
  • No re-flow: the normal flow in the coronary arteries is not restored after the insertion of a device

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