High-Speed Rotational Coronary Atherectomy. Ischemic and non Ischemic Complications

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Abstract

Background High-speed rotational coronary atherectomy has shown to be useful in the treatment of complex lesions. The method is not devoided of complications and a detailed report on the subject is still missing. This is the main aim of the present paper. Material and method From december 1991 to march 1994, 250 arteries/231patients were submited to rotational atherectomy. A Rotablator device was used until at least a 20%reduction in obstruction and absence of rotational gradient are observed. Each procedure was completed with balloon-angioplasty to optimize the lumensize. All patients wore a bipolar electrode-catheterin the right ventricular apex during the procedure, and were maintained under heparin for the next 24 hours. Results Primary success (at least a 20% reduction of the previous obstruction, with a final residual obstruction lesser than 50%, without major complications such as AMI with new Q waves, emergency surgery or death) was seen in 96%, and major complications in 1.73% of cases (Q wave MI: 0.86%; emergency by-pass surgery: 0.86%). Three patients had sub-acute occlusions successfully re-dilated with balloon-angioplasty. In 4 cases (1.6%) side branch occlusions occurred. Transient spasm was seen in 14% of cases. In one patient a focal ulcerated crater was produced in the left main artery following the advance of the rotating device. Cardiac tamponade was seen in 2 patients (0.86%). In one of the cases it appeared sub-clinically, secondary toan artery ulceration with possible perforation. In the other case it was associated with an electrode-catheter perforating the right ventricle. In both a pericardial puncture solved the problem. Guide wire fracture with dislodgement in minor branches were solved medically in 2 cases and with elective surgery in the other two. Transient arrhythmias occurred during the Rotablator advancement: sinus bradycardia (2%),181and 2nd AV block (0.8%) and atrial fibrillation (1.2%). Complete AV block was seen in 29 cases (11.6%) and it was related to the treated artery (RC 26.74%; Cx 6.97%; LAD 2.47%;p < 0.000001). All were solved with temporary pacing. Conclusions In patients submitted to high-speed rotational atherectomy: 1) Ulceration-perforation and subacute occlusion of the coronary artery is possible but not commonly seen. 2) Transient complete AV block is frequent and even more when the right coronary artery is treated, but without consequences if temporary pacing is provided. 3) Chances of guide wire fracture and dislodging enhances the need to carefully control wire location during the procedure.