This document discusses complications that can occur during rotational atherectomy and their management. It notes that complications include bradycardia, slow or no blood flow, dissection, perforation, side branch occlusion, hypotension, and device failures. Proper guidewire placement and limiting ablation times can prevent many complications. Slow or no flow is managed with vasodilators, fluids, and pacing. Dissections may require stenting. Device failures like burr entrapment require vigorous vasodilation. Being prepared to address complications promptly is key to achieving success during this procedure.

1. “Rotational Atherectomy”
Complications And Management
DR NILESH TAWADE
JASLOK HOSPITAL MUMBAI

2. INTRODUCTION
• RA is associated with complications similar
to other percutaneous procedures as well
as unique to this device .
• Entire catheterization staff should have a
thorough understanding of these
complications so that appropriate
management can be expedited.

3. Complications
• Bradycardia and
Atrioventricular blocks
• Slow Flow Or No Reflow
And Vasospasm
• Dissection
• Perforation
• Side branch occlusion
• hypotension
Rotabalator System
Failure
•Burr Entrapment .
•Burr Detachment.
•Burr Stalling.
•Rota Guide Wire
Fracture.

4. Bradycardia And Atrioventricular Block
• Incidence : more common with RCA
lesions > dominant left circumflex A > can
occur with proximal LAD when large burrs
(2.25mm) are used .
• It can occur instantly after activating the
burr or can follow slowing trend of the burr.

5. Bradycardia And Atrioventricular Block
• Mechanism of bradycardia or AVB.
- Unclear
- Various Theories
• micro particles interfering with vessels per fusing AV
node
• vibrations and heat of burr causing reflex bradycardia.

6. Management of Bradycardia And
Atrioventricular Block
• Prevention
Limiting ablation times (<15-
20sec)
Pretreatment with Atropine
 Deactivate the burr when
slowing of heart rate is noted
Ask the pt to cough

7. Management of Bradycardia And
Atrioventricular Block
• Some operators advances pacemaker only into
the IVC and place it into the RV when needed.
• Present recommendations are the placement of
temp pacemaker in pts under going treatment of
RCA ,Dominant LCX, proximal LAD giving
collaterals to RCA .

8. Management of Bradycardia And
Atrioventricular Block
• Pacemaker usually set at 50bpm .
• It should be tested prior to the procedure for
assessment of ventricular capture.
• Blood pressure may drop from during pacing so
prior proper hydration is necessary.
• Since the coronary blood flow is compromise
during pacing , limiting run times during pacing is
recommended .

9. Slow flow and No Reflow
• It is most challenging adverse sequelae.
• Observed in 5% pt undergoing treatment with
rotablator.
• Slow flow : diminution of flow by 1 -2 TIMI grades from
base line.
• No Reflow : Cessation of flow into the distal vessel
which is treated or back and forth movement contrast
without clearing from the vessel.

10. Mechanism Of Slow Flow Or No Flow
• Excessive plaque burden and long lesion
• Long ablation time
• Vasospasm
• Platelet activation
• Micoparticulate aggregation
• Treatment of the vessel in the previously
infarcted segment

11. Slow Flow And No Reflow
Management
• “No flow” has more deleterious impact
• Once observed no further burring should be done.
• Intra coronary NTG , VERAPAMI, ADENOSINE should be given
adequately .
• Blood perfusion : forcefully re injecting it . (mechanism:-
accelerate particle clearance and perfuse the vessel)
• Maintain adequate perfusion pressure either with Hydration
or Vasopressors or IABP.

12. Slow flow and No Reflow
• Ability to differentiate slow flow and no reflow from abrupt
closure or flow limiting dissection is important .
• Because they distinctly different treatments
• Abrupt closure from severe dissection or flap should be
treated with prolonged balloon inflations or stenting.
• And prolonged balloon inflations will not improve situation in
case of slow or no flow
• Sometimes severe vasospasm is difficult to differentiate from
no flow . Although the treatment is similar.

13. Slow Flow And No Reflow
Management
• Adjunctive PTCA is useful in this situation, this
will help to relieve the spasm and balloon may
acts like “plunger” to accelerate the passage
of blood
• Gp IIb/IIIa inhibitors are very beneficial in this
situation.

14. Management of Bradycardia And
Atrioventricular Block
• In summary , the management of slow flow or no
reflow requires the integration of several
techniques and aggressiveness of the operator
as they set up the kind of “vicious cycle”
• Once flow has been re-established the ECG
begins to normalize but, It will not return to
baseline even if the epicardial vessels are
visualized .
• pts chest pain begins to improve but requires
time for complete resolution (usually >20 min)

15. Prevention of slow and no flow
• Deploying burr in step method to minimize the effect of plaque
burden for given burr size.
• Gentle advancement and intermittent retraction helps in preventing
 drop in rpm <5000
 significant generation of heat and
 reestablishment of flow for particle clearance
• Limiting the ablation time to 15-30 seconds.
• Increasing the time between the ablations
• Slower speed (140,000 rpm) associated with lower platelet
aggregation , so beneficial.
• Prior use of GPIIb/IIIa very usefull.(abciximab)

16. Dissection
• Incidence 10%
• In cases with mod to severe angulated lesions
dissections are more commonly noted because at
angles, burr dose not follow the natural course of the
vessel.
• Guide wire vector would cause the orientation of the burr
to be out of planes, and result in tangential ablation with
potential dissection
• Therefore placement of the guide wire plays paramount
role in establishing the cutting vector of the device .

17. Dissection
• Goal is to set the optimal central vector for burring.
• Because increased tension (rigidity) on the wire can cause
psudolesions in the vessel and increased stiffness of the
vessel can cause tension on the wire and it will affect the
advancement of the burr.
• Angiogram should be performed after the placement of the
wire to assess the interaction between the two.

18. • Guide wire “unfavorable” bias can increases the
chances of dissection and burring of the normal
tissue.

19. HOW TO MINIMIZE THE “BIAS”
• Retracting the Rota guide wire to proximal position may
improve co axial alignment at the lesion site and prevent
psudolesions formation distally .

20. How To Minimize The Rota Guide Wire
Tension
• Tension on guide wire can be
relieved by first relieving the
drive shaft tension by retracting
it by approximately 1 cm, once
the burr has reached proximal to
the lesion.
• Visualization under fluoroscopy of
the burr retracting indicates
tension has been relieved
• This relief of tension also prevents
burr from lurching forward after
activation and causing trauma.

21. Special situations
• Another common site prone to dissection
is ostium of severely angulated circumflex
artery.
• Stiffness of the wire can eccentrically orient
the burr and force the burr to preferentially
ablate on the inner aspect of the vessel.

22. • In case of ostial circumflex on a severe bend ,
attempt to telescope the guide catheter to
remove the angle ,
• Amplatz GC can be helpful
• If alignment can not be achieved then
undersize the burr for a maximum A:B ratio of
0.5 to 0.6.

23. • Location of dissection plane usually
remains in the calcified plaque which is
ablated.
• Dissections can be managed by deploying
oversized balloon at low pressure to tack
up the tissue and then stenting.

24. Perforations
• Incidence 0.7% reported from multicentre registry.
• Mechanism:- Oversize burr OR Tangentially oriented burr due to
trajectory of guide wire .
• More common in severely angulated lesions,
• This can occur even in elastic vessels , since the strain or
penetration of guide wire in to the wall will exceed the elasticity of
vessel wall and ablation of tissue will occur and potential
perforation .

25. Management
• Therefore the methods to avoid perforation are to minimize guide
wire bias by proper co- axial guide catheter and guide wire
placement
• Relaxation of the guide wire is important.
• Undersize the burrs in severely angulated lesions especially those
are straightened with guide wire or showing psudolesions.
• “pecking” technique should be used to avoid excessive cutting .

26. Side Branch Occlusion
• Since the secondary protective wire cannot be used with Rot
ablator system so careful attention should be given.
• In most of the cases it is due to micro particle debris or
vasospasm in contrast to usual PTCA in which it is due to
plaque shift.
• To prevent occlusion, burr can be platformed distal to the
take off of the side branch if possible
• Vasospasm generally responds to vasodilator therapy.

27. Side Branch Occlusion
• If not responded to vasodilators then low pressure
balloon dilatation at the site of spasm is sometimes
worthwhile.
• Bifurcation treatment depends on the size of the side
branch
• Two approaches are possible 1) ablate both limbs or 2)
ablate one and dilate the other
• In case LAD/ Diagonal Bifurcations , large diagonals are
ordinarily ablated
• While Smaller diagonals are treated with dilatations

28. Side Branch Occlusion
• Initiate the burring or pre-dilatation in the
limb in which it is technically difficult to
place the guide wire provided its “Large”
as parent vessel.
• usually with ostial lesions in the side
branch can be ablated with undersized
burr if they are not dilatable with low
pressure dilatations.

29. Hypotension
• In rotablator procedure antecedents of
hypotension episodes can
 vasospasm ,
 slow and no reflow,
 bradycardia and
 inadequately hydrated patients
 pts on large dose of vasodilators

30. Management of hypotension
• Coronary blood flow is major determinant of particle
clearance.
• Therefore at the starting of the procedure pt should not
be hypovolemic and if its ,then procedure should be
delayed until fluids are administered.
• If intra procedural hypotension occurs after ablation,
infusion of fluids should be done
• and if associated with slow flow or no reflow
immediately start vasopressors and placement of IABP
will be very helpful.

31. Rotablator System Failure
• Despite mechanical complexity of the system ,device
failure is a rare event.
• Majority of device failure due to use of the device
outside the standard operations.
• These are
burr entrapment
burr detachment
burr stalling
guide wire fracture

32. Burr Entrapment
• Can occur if a burr slips across
the lesion without the burring
(coefficient of friction is less at
the high speed than at the rest ).
• Ledge of the calcium behind the
elliptical burr causes “Kokesi”
effect.
• It may get entrapped in the
tortuous segment of the lesion

33. Management Of Entrapped Burr
• Vigorous use of vasodilators

34. Management Of Entrapped Burr

35. Management Of Entrapped Burr

36. Management Of Entrapped Burr

37. Management Of Entrapped Burr

44. BURR DETACHMENT
• Associated with excessive force applied to remove non
spinning burr from tortuous artery.
• To avoid this ,do not use burrs with less than 0.004”
clearance for the GC.
• If clearance is less than 0.004” then slow
inactivated withdrawal of burr is best method to enter
GC.
• while exchanging the burr verify that GC is in co axial
position with the artery so burr doesn't get trapped
onto tip

45. BURR DETACHMENT
• If burr detaches from the driveshaft cable, the
distal tip of the guide wire is 0.017” , so it will
keep the burr from exiting the end of the guide
wire.
• So entire guiding catheter and guide wire
system can be withdrawn after giving adequate
intracoronary vasodilators.

46. BURR STALLING
• When there is significant resistance to
rotation.
• Kinking of the air hose
• Over tightening of the “Y” connector
• B: A ratio 1.0
• Aggressive advancement in tight lesions
• Spasm in the platform zone
• Operation without saline infusion.

48. GUIDE WIRE FRACTURE
• Result of excessive rotation of the burr in
angulated and tortuous arteries.
• Long ablation time
• Formation of loop of which fractures as
operator pulls on the wire to remove the
loop.

49. How to minimize the problem
• Keep the GW out of small branches.
• Reposition the GW frequently during the excessively
long ablations.
• Fasten the wire clip properly.
• Avoid prolapsing the guide wire tip.
• Inject contrast to demonstrate the flow around the
guide wire.

50. Retrieval Of Fractured Wire
• Fractured guide wire portions can be retrieved with the
different types of SNARES and retrieval BASKETS or
FORCEPS
• If unsuccessful and of no hemodynamic consequences
can be left alone with conservative medical
management.

51. SUMMARY
• To achieve high success and low complications, cardiologists and technical staff must be
WELL PREPARED to address the complication during the procedure.
• Trained personnel for this procedure should be accessible if problem arises.
• Vasospasm and slow flow and no reflow phenomenon are frequently amenable to
pharmacological intervention
• If clinical status of the pt deteriorate and pt is unresponsive to the therapy then surgical
intervention is anticipated as optimal timing is essential for maximum myocardial salvage.