Significant coronary calcification is a major
challenge and limitation for percutaneous coronary
intervention, as it inhibits stent placement and
expansion. This may be associated with poor stent
expansion, target lesion restenosis, stent thrombosis,
and myocardial infarction (MI).[
10]
In the ROTAXUS (Rotational Atherectomy
Before TAXUS Stent Treatment for Complex
Native Coronary Artery Disease) study,
240 patients with complex calcified native
coronary lesions were randomly assigned to two
groups: RA followed by stenting (n=120) and
stenting without RA (n=120, standard treatment
group). Despite similar baseline characteristics,
the strategy resulted in higher success in the
rotablator group (92.5% vs. 83.3%, p=0.03), but restenosis (10.6% vs. 11.4%, p=0.71), target lesion
revascularization (12.5% vs. 11.7%, p=0.84), stent
thrombosis (0.8% vs. 0% p=1.0), and major adverse
cardiovascular events (24.2% vs. 28.3%, p=0.46)
were similar in both groups.[6]
Another recent study that included 154 patients
showed comparable clinical results at 30-day and
one-year follow-ups in those who did or did not
undergo the RA procedure in acute MI.[11] This study
demonstrated the safety and efficacy of RA in patients
with acute or recent MI and reported that RA is a
viable option due to a high procedural success rate.
In the literature, RA has been successfully applied
to calcific lesion in patients with acute STEMI and
subacute MI.[12,13] In a prospective study of 76 patients
with calcific superficial femoral artery lesions longer
than 150 mm treated with drug-coated balloon
angioplasty (DCB) alone or directional atherectomy prior to DCB, primary coronary artery patency of the
DCB and directional atherectomy with DCB groups
at the 12-month follow-up was 66.6% and 82.6%,
respectively (p<0.05).[14]
In light of the information we obtained in our
case, the use of a rotablator before stent implantation
in highly calcified coronary lesions reduces the risk
of acute occlusion by providing a smoother lumen,
provides increased lumen gain, reduces residual
plaques, and reduces the risk of stent thrombosis
through stent expansion and placement. Furthermore,
RA is a proven procedure to modify the coronary
lesions and facilitate stenting in severely calcified
lesions when high-pressure balloon angioplasty alone
cannot achieve dilation. In our case, the RCA lesion
could not be opened despite high pressure with a
balloon dilatation, and a combination of RA and
DES was used. Rotational atherectomy and DES are
complementary techniques in highly calcified lesions.
Due to the inadequacy of data in the literature, new
randomized clinical trials are needed to accurately
evaluate these approaches.
In conclusion, the use of a rotablator before stent
implantation in severely calcified coronary lesions
provides a smoother lumen, reducing the risk of acute
occlusion and providing comfortable expansion and
placement of the stent.
Patient Consent for Publication: A written informed
consent was obtained from the patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Idea/concept, design, data
collection, literature review, writing: M.K.; Control/
supervision, critical review: N.B.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.
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