Intermediate Stenosis
Rotational Atherectomy

The lesion shown above presented a diagnostic challenge. This patient presented with an acute coronary syndrome. He was found to have diffuse coronary artery disease. He has had diabetes for many years and takes oral agents with good glucose control. He also has thrombocytopenia with a platelet count of 60-80k. IV Platelet inhibitors were contraindicated but he was treated with aspirin and heparin.

All of his major epicardial coronary vessels have diffuse plaque and the mid LAD shown above is no exception. We had expected to find at least one focal narrowing of 90% or more based on his presenting symptoms. While the mid LAD segment certainly has disease, the severity of this lesion was uncertain based on multiple angiographic views. In an effort to determine its significance, this lesion was evaluated by intravascular ultrasound. The IVUS image demonstrated heavy plaque (in excess of 270 degrees in some areas) and severe plaque burden with significant luminal narrowing. Alternatively, this lesion could have been evaluated with pressure wires to calculate the functional fractional reserve. Because of the diffuse disease seen by IVUS, the lesion was preferentially treated with Rotational Atherectomy utilizing the 'stepped-burr' approach and ultimately, a 2.38mm burr was passed through this area (9F guide). After adjunctive balloon angioplasty with a 4 mm balloon at low pressure, angiography demonstrated a very smooth appearance and there was no evidence of dissection. This lesion was not stented.

Rotational atherectomy works by debulking plaque. It utilizes a mechanism called differential cutting which ablates hard, calcific tissue while leaving softer, non or less diseased areas untouched. Using the proper technique, rotational atherectomy is well suited for lesions such as this that are diffusely diseased with areas of heavy calcification. Often times, rotational atherectomy either alone or with adjunctive low pressure balloon dilatation will produce 'stent-like' results with clinical target lesion revascularization rates similar to stented segments.