Researchers successfully perform ostial right coronary artery CTO recanalization using rotational atherectomy in subintimal space

Severely calcified ostial CTO percutaneous coronary intervention (PCI) is challenging with a high prevalence of balloon uncrossable lesions. Despite the higher aortic dissection and perforation risk, rotational atherectomy (RA) may be used as a bailout strategy for uncrossable lesions. The authors note that the objective is to modify the subintimal space with dissection and re-entry (DR) techniques in the ostial/proximal coronary segment to advance the devices and cross the proximal CTO cap.

Marcelo Harada Ribeiro, SOS Cardio Hospital, Florianopolis, SC, Brazil, and colleagues describe the successful use of subintimal RA in a balloon-uncrossable ostial right coronary artery (RCA) CTO in a 78-year-old man.

The man had a history of CABG (coronary artery bypass surgery) 10 years ago and presented with medically refractory angina. After a failed previous attempt, he was referred for RCA CTO PCI. Coronary angiography showed a severely calcified ostial RCA occlusion filling by septal collaterals from the left anterior descending artery (LAD). There were patent saphenous vein grafts (SVGs) to the left anterior descending (LAD) and the ramus.

According to expert recommendations, RA should not be performed in dissection planes due to perforation risk.

"Our case describes the successful use of rotational atherectomy in the extra plaque space of an ostial RCA CTO lesion," the authors wrote. In CTO PCI, experience with RA in the extra plaque space is limited, once RA carries a higher risk for complications, particularly in CTO PCI."

The authors recommend using high-speed (180,000 rpm) with very short runs and mainly in straight segments in balloon-uncrossable ostial CTOs when RA is needed as a bailout strategy for subintimal calcium modification.

Reference:

Ribeiro, M. H., Dallan, L. A. P., Quesada, F. H., Rodriguez, F. H., Silveira, C., Megaly, M. S., Brilakis, E., & Azzalini, L. (2023). Extra-plaque rotational atherectomy for treating a balloon uncrossable ostial right coronary artery chronic total occlusion. Cardiovascular Revascularization Medicine. https://doi.org/10.1016/j.carrev.2023.06.002