Outcomes with Orbital and Rotational Atherectomy for Inpatient Percutaneous Coronary Intervention

Overcoming Uncrossable Calcified RCA Using Orbital Atherectomy After Failure of Rotational Atherectomy

Severe calcified lesions in the coronary arteries often pose significant challenges for successful percutaneous coronary interventions. In this case, a 78-year-old woman presented with severe calcific disease in the right coronary artery and underwent two sequential interventions. The initial procedure involved rotational atherectomy but failed to fully cross the lesion. The procedure was complicated by an ostial dissection that was treated by stent. Subsequently, orbital atherectomy was employed, successfully crossing the lesion through a newly deployed ostial stent. Additionally, upfront intracoronary adenosine was administered to prevent no-reflow, achieving optimal procedural outcomes. This case highlights the utility of orbital atherectomy as a rescue technique after failed rotational atherectomy and the effectiveness of proactive pharmacological intervention for no-reflow prevention. To our knowledge there were no case reports addressing successful orbital atherectomy following failed rotational atherectomy.

New Frontiers for Orbital Atherectomy-Crossing an Uncrossable Chronic Total Occlusion

Managing chronic total occlusions (CTOs) in coronary artery disease remains a significant challenge, especially in cases where standard techniques fail to cross the lesion. Uncrossable lesions are rare but require innovative strategies for successful treatment. Orbital atherectomy, traditionally used for calcified plaques, may offer a solution in these cases. We present the case of a 62-year-old male with exertional chest pain and a CTO in the right coronary artery (RCA). The patient had a positive stress echocardiogram for inducible ischemia despite optimized medical therapy. Multiple conventional techniques, including ballooning, microcatheter use, and laser atherectomy, failed to cross the proximal cap of the CTO. After these methods proved ineffective, orbital atherectomy using the DiamondBack 360 system successfully crossed the lesion and enabled subsequent balloon angioplasty and stenting. This may be the first reported case where orbital atherectomy was used after the failure of laser and other techniques. The case highlights the role of orbital atherectomy in the treatment of uncrossable CTOs, expanding its application beyond calcified lesions. The versatility of this technology, particularly when other methods fail, underscores its importance as an adjunctive tool in complex PCI. In conclusion, orbital atherectomy should be considered a valuable option for crossing uncrossable coronary CTOs, especially when standard and advanced techniques, including laser atherectomy, fail. This case broadens the scope of its use in coronary intervention, providing a new perspective on tackling resistant lesions.

Safety and Efficacy of Orbital Atherectomy in the All-Comer Population: Mid-Term Results of the Lower Silesian Orbital Atherectomy Registry (LOAR)

BACKGROUND

Coronary calcifications represent a challenging subset for the interventional cardiologist performing percutaneous coronary intervention (PCI) and are well-established risk factors for adverse outcomes. Adequate plaque modification prior to stent implantation is critical to achieve an optimal outcome following PCI. Recently, a novel orbital atherectomy device has been introduced into clinical practice to modify calcified plaques. We evaluated the mid-term safety and efficacy of OA in a high-risk "all-comers" population.

METHODS

We evaluated 96 consecutive patients with severely calcified coronary lesions who underwent PCI facilitated by the orbital atherectomy device.

RESULTS

In-hospital MACCE was 5.2% without target lesion revascularization. At 6-month follow-up, the MACCE rate was 10.4% with a concomitant TLR rate of 1%.

CONCLUSIONS

Our mid-term data showed good safety and efficacy of orbital atherectomy as a plaque-modifying tool in an all-comers cohort with severely calcified coronary lesions.

Prognostic Value of Angiography-Derived Index of Microcirculatory Resistance in Patients with Coronary Artery Disease Undergoing Rotational Atherectomy

Background

Rotational atherectomy (RA) is the major tool used to treat severely calcified lesions in patients with coronary artery disease (CAD). The relationship between coronary microvascular dysfunction and RA remains unknown. Therefore, we attempted to explore the predictive implications of the coronary angiography-derived index of microcirculatory resistance (angio-IMR) in CAD patients undergoing RA.

Methods

This retrospective study included 118 patients with severe coronary calcification who underwent a successful RA from January 2018 to June 2021. The angio-IMR was calculated based on computed flow and pressure dynamic principles to assess coronary microcirculatory function. Follow-up was performed on all patients for major adverse cardiovascular events (MACEs), including all-cause death, non-fatal myocardial infarction, target vessel revascularization (TVR), and stroke.

Results

The mean angio-IMR for all patients was 25.58 ± 7.93. Patients were stratified the groups based on a mean angio-IMR of 25, fifty-four (45.8%) patients had angio-IMR ≥ 25. The logistic regression analysis showed that angiography-derived fractional flow reserve was significantly associated with coronary microvascular dysfunction. After median follow-up of 21.7 (15.1-24.0) months, MACEs occurred in 30.6%, including 12.5% all-cause deaths, 6.4% non-fatal myocardial infarction, 14.5% TVR, and 0.9% stroke. Kaplan-Meier analysis demonstrated that patients with angio-IMR ≥ 25 had greater cumulative MACEs (41.6%) and TVR (20.7%) than patients with preserved angio-IMR. COX regression analysis indicated that angio-IMR ≥ 25 and reduced left ventricular ejection fraction were independent predictors of MACEs. In addition, angio-IMR ≥ 25 and lowered minimum luminal area independently predicted TVR occurrence.

Conclusions

In CAD patients undergoing RA, angio-IMR ≥ 25 was an independent and significant predictor of MACEs and TVR.

Clinical Trial Registration

NCT05435898.

Outcomes of Orbital Atherectomy for the Treatment of Severely Calcified Coronary Artery Lesions

Background Orbital atherectomy (OA) is used to prepare severely calcified coronary artery lesions before percutaneous coronary intervention (PCI). Intravascular ultrasound (IVUS) is used to determine the plaque volume and degree of stenosis within the arterial vessel. This study evaluated the safety and efficacy of OA for treating severely calcified coronary lesions and determined if IVUS impacted these outcomes. Methods We retrospectively collected data from a single center of patients with severe coronary artery calcification who underwent OA. The data on baseline characteristics and procedural and clinical outcomes were collected and analyzed. Results A total of 374 patients underwent OA. The mean age was 69 ± 12.7; 53.6% were Black, and 38% were female. Hypertension was present in 96% of the patients, followed by hyperlipidemia in 79.4%, diabetes mellitus in 53.7%, and chronic kidney disease (CKD) in 22.7%. More patients had presented with a non-ST-elevation myocardial infarction (NSTEMI) compared to ST-elevation myocardial infarction (STEMI) at 36.3% versus 4.3%, respectively. The radial artery was used in 35.4% of the cases, and the left anterior descending artery (LAD) was the most commonly treated vessel with OA at 61%, followed by the right coronary artery (RCA) at 30.7%. IVUS was utilized in 63.4% of cases. The most common complication of the procedure was perforation and dissection at an equal proportion of 1.3% among all patients. The no-reflow rate was 0.5%, and 0.5% developed post-procedural myocardial infarction (MI). The average length of stay was 4.7 days, while a marginal proportion, at 10.5%, had same-day discharge with no recorded complications. Conclusion In this analysis of patients with severely calcified coronary lesions, OA had low rates of major adverse cardiovascular events (MACE) and was considered a safe and effective treatment for complex coronary lesions.

Initial experience with orbital atherectomy in a tertiary centre in the Netherlands

Background

In January 2021, the Diamondback 360 orbital atherectomy (OA) system received CE mark approval and became available in Europe. The first procedure in Europe was performed at the Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.

Aims

To report the procedural safety and efficacy of the initial experience with OA in a tertiary care institution in the Netherlands.

Methods

Patients with de novo severely calcified coronary artery disease who were treated with intended invasive imaging-guided OA were included in a prospective single-centre registry. Device success, defined as less than 50% stenosis after OA, and procedural success, defined as successful stent implantation with less than 50% residual stenosis, were evaluated. Calcium debulking effects were assessed by invasive imaging. Safety was assessed up to 30 days after the index procedure.

Results

Between February 2021 and June 2021, 29 patients with a total of 39 coronary arteries underwent OA. Target lesions were heavily calcified with a mean length of 32 mm and a calcium arc of 320 degrees. Invasive imaging was applied in all but one patient and 36 vessels. Superficial sanding was observed in almost all vessels (90%) and fracturing of deeper medial calcium in more than half of the vessels (63%), with a device success of 66% and procedural success of 94%. The mean stent symmetry index was 0.84, indicating good circular stent expansion. No primary safety events occurred during 30 days of follow-up.

Conclusion

Our initial experience with OA for heavily calcified coronary lesions demonstrated favourable debulking effects and plaque modification, with high procedural success and clinical safety.