Rotational Atherectomy For Treating Calcified Lesions in Unprotected Left Main Coronary Artery: Single Center Experience

Background: Percutaneous coronary intervention (PCI) of the unprotected left main coronary (LM) may achieve suboptimal outcome in the presence of severe vascular calcification. Rotational atherectomy (RA) is used for modifying calcified plaque prior to stenting, however use of this device may be complicated by severe myocardial ischemia due to coronary no-reflow or vessel obstruction. We report our experience using RA for treating severely calcified LM lesions.

Methods: Our prospective institutional catheterization laboratory database was reviewed. All cases of RA-assisted LM-PCI were evaluated. Clinical characteristics, procedural data and clinical outcomes were collected.

Results: 136 patients underwent LM-PCI at our institute between January 2016 and December 2020. Twenty-nine of these patients (21%) underwent RA-assisted LM-PCI. Mean age was 79±10 years, 38% were female, left ventricular ejection fraction was 49±11% and 5 patients (17%) were on chronic dialysis treatment. Eighteen patients (62%) were considered to have high-risk anatomy predisposing them to hemodynamic compromise if the procedure was complicated by LM occlusion [severe aortic stenosis=4 (14%), chronic right coronary occlusion=2 (7%), ejection fraction<40%=7 (24%), left dominant coronary anatomy=6 (21%)]. Intra-aortic balloon counterpulsation was used in 3 patients (10 %), intravascular ultrasound was used in 4 (14%) and a temporary pacemaker was implanted in 4 (14 %). Mean number of RA burrs used was 1.9±0.4 mm (size range: 1.25-2.0 mm) and mean number of stents implanted was 3.3 ± 1.7. Angiographic success was achieved in all patients, including a single patient who sustained a coronary perforation. There was no procedural mortality, despite 2 patients requiring cardiopulmonary resuscitation. Median hospital stay was 6.5±4.2 days, 30-day mortality was (11 %) and 1-year mortality was 40 %.

Conclusion: In high-risk patients, RA of the LM coronary artery can be performed safely and is associated with a high rate of angiographic success.