Coronary Atherectomy
By Nadia Sutton, MD, MPH
Pearl 1. Keep Skills Up to Date
When it comes to atherectomy, it is important for interventional cardiologists to have at least one device that they feel comfortable with. We know that atherectomy is used in the minority of coronary interventions in the cath lab, especially with the availability of coronary lithotripsy. So, it is important for us to keep our skills up to be able to use atherectomy devices, because they definitely have their place. There are circ*mstances in which you will need atherectomy because lithotripsy or specialty balloons do not provide sufficient calcium modification.
Pearl 2. Use Intravascular Imaging
When performing atherectomy or any type of calcium modification, intravascular imaging is recommended. Ideally, one would perform the intravascular imaging before performing calcium modification to understand the characteristics of the calcium and choose the optimal device. But, sometimes it’s not possible to deliver the imaging device before calcium modification, in which case one should try to do it as soon as possible during the procedure.
Pearl 3. Make Use of Industry Support
Utilize your support and industry partners for support in using these devices. Experienced representatives visit many different hospitals and have seen a lot of cases using their respective devices. This is not only for the benefit of the operator but also for the cath lab staff. Many cath labs have experienced staff turnover, and some staff may not be as familiar with the setup. Industry partners have been trained to teach others, so leverage that resource.
Pearl 4. Stay Informed
Make sure you’re periodically staying up to date, reviewing the available devices and their capabilities, sizing considerations, and guide and guide extender compatibility with the devices. A Society for Cardiovascular Angiography and Interventions (SCAI) Expert Consensus Statement on the management of calcified coronary lesions was published in early 2024 in JSCAI, which makes for a great guideline resource (see General Tips from the SCAI Expert Consensus Statement sidebar).1
Pearl 5. Maintain Case Volume
Do not use the atherectomy device only when it’s the most severe lesion or the most complicated patient. Ultimately, it is a good idea to proactively make sure you’re maintaining a volume of appropriate cases to ensure that both you and your staff are up to date and facile with these devices. If it’s been a while since you performed an atherectomy and it is clinically appropriate to use atherectomy or another calcification modification tool, it may be wise to consider choosing atherectomy to ensure you’re maintaining your skills.
General Tips From the SCAI Expert Consensus Statement
Rotational Atherectomy
Tip 1.
Make sure the wire is kept in the field of view and that the burr is at least 5 mm away from the radiopaque distal segment of the wire to avoid wire fracture.
Tip 2.
Use the pecking motion with a short duration of atherectomy, < 30 seconds. Shorter durations allow flow down the artery and prevent problems with no reflow.
Tip 3.
Avoid burr deceleration > 5,000 rpm to reduce the risk of complications related to slow flow or burr entrapment.
Orbital Atherectomy
Tip 1.
Keep the distal tip in the field of view, at least 5 mm from the drive shaft tip, to avoid fracture of the distal portion of the wire.
Tip 2.
Use a smooth forward and backward motion at approximately 1 mm per second and never force movement.
Tip 3.
The number of runs is associated with the lumen gain. The more runs, the higher the lumen gain.
Further Reading: For more information overall on coronary atherectomy, see the SCAI Expert Consensus Statement in reference 1.
1. Riley RF, Patel MP, Abbott JD, et al. SCAI expert consensus statement on the management of calcified coronary lesions. JSCAI. 2024;3:101259. https://doi.org/10.1016/j.jscai.2023.101259
Nadia Sutton, MD, MPH
Assistant Professor of Medicine
Division of Cardiovascular Medicine
Vanderbilt University Medical Center
Nashville, Tennessee
nadia.sutton@vumc.org
Disclosures: Speaker and/or consultant for Abbott, Boston Scientific, Philips, and Zoll.
Coronary IVL
By Robert F. Riley, MD, MS, FACC, FAHA, FSCAI
Pearl 1. Utilize Intravascular Imaging
Utilize intravascular imaging to characterize the location and type of calcium present. Angiography has been shown to have poor predictive value for significant coronary calcification, and intravascular imaging can help you select the correct tool for the target lesion.
Pearl 2. IVL Balloon Sizing
Size your intravascular lithotripsy (IVL) balloon 1:1 with the vessel size for the target lesion (ideally with intravascular imaging). This allows for proper apposition of the balloon and minimizes proximity of the emitters to the calcium, ensuring optimal therapy delivery.
Pearl 3. Use of Ancillary Devices
Utilize guide extensions, stiffer wires, and/or “buddy wires” to help deliver IVL balloons through tortuous anatomy. These ancillary devices can help deliver the IVL balloon through challenging lesions, particularly when using a radial approach.
Pearl 4. Atherectomy and Use of Noncompliant Balloons
When atherectomy is used as an up-front strategy, consider the use of 1:1-sized noncompliant (NC) balloons and/or repeat intravascular imaging to evaluate for proper vessel preparation after atherectomy is complete. When using NC balloons, ensure full inflation at nominal pressure in multiple views as evidence that vessel preparation is complete. When using intravascular imaging, evaluate for the presence of fractures in the calcified segments. Even after using atherectomy, IVL can help modify longer, thicker segments of calcium that atherectomy will not adequately modify.
Pearl 5. Managing Balloon Rupture
When an IVL balloon ruptures, take a second balloon and inflate it to 2 atm to deliver pulses. IVL balloons often rupture on spicules or nodules of calcium and IVL balloons at low-pressure inflation will still appose the lesion and allow for modification.
Robert F. Riley, MD, MS, FACC, FAHA, FSCAI
Director, Interventional Cardiology & Cardiac Cath Labs
Director, Complex Coronary Therapeutics Program
Overlake Medical Center & Clinics
Bellevue, Washington
robert.riley@overlakehospital.org
Disclosures: Consultant to Shockwave Medical.
