Rotational atherectomy and intravascular lithotripsy — two methods versus single lesion

Adrian Włodarczak1, Jan Kulczycki1, Łukasz Furtan2, Piotr Rola3, Mateusz Barycki3, Magdalena Łanocha4, Marek Szudrowicz1, Maciej Lesiak5

1Department of Cardiology, MCZ Hospital, Lubin, Poland

2Department of Internal Medicine, District Hospital in Olawa, Oława, Poland

3Department of Cardiology, Regional Specialist Hospital, Legnica, Poland

4St. Adalbert’s Hospital, Poznań, Poland

51st Department of Cardiology, University of Medical Sciences, Poznań, Poland

Correspondence to:

Jan Kulczycki,

Department of Cardiology, MCZ Hospital,

Skłodowskiej-Curie 52, 59–300 Lubin, Poland,

phone: +48 885 169 245,

e-mail: jan.jakub.kulczycki@gmail.com

Copyright by the Author(s), 2021

Kardiol Pol. 2021; 79 (6): 712–713; DOI: 10.33963/KP.15962

Received: March 4, 2021

Revision accepted: April 11, 2021

Published online: April 16, 2021

Intravascular lithotripsy (IVL) and rotational atherectomy are two different device designs dedicated to overcome their common enemy heavily calcified lesions. Percutaneous coronary interventions in this kind of lesions are associated with a higher risk of periprocedural complications, such as dissection or perforation of the vessel, distal embolization, or device entrapment [1]. Rotational atherectomy is a well-established procedure with proven superiority over scoring balloons [2]. Intravascular lithotripsy is a relatively novel approach to heavily calcified lesions [3, 4], recently approved by Food and Drug Administration (FDA) in this indication.

An 81-year-old woman with a history of hypothyreosis, and persistent atrial fibrillation, on rivaroxaban treatment, was admitted to the Cardiology Department to undergo urgent percutaneous coronary interventions of the heavily calcified left anterior descending artery (LAD). Initially, the patient had been admitted to a remote hospital due to non-ST-segment elevation myocardial infarction. Coronary angiography revealed chronic total occlusion of the recessive right coronary artery and significant LAD stenosis (Figure 1A).


High pressure predilatations (22 atm) with non-compliant (NC) balloons (2 × 18 mm; 2.5 × 20 mm) were unsuccessful. After the first procedure, bleeding from the lower gastrointestinal tract occurred.

Subsequently, the patient was referred to the Cardiac Intervention Unit capable of performing IVL and rotational atherectomy procedures. Laboratory tests on admission revealed severe anemia (hemoglobin, 7.1 g/dl) and coagulopathy (international normalized ratio [INR], 15.27). After blood transfusions and vitamin K administration, due to persistent angina symptoms, the patient underwent angioplasty within 24 hours after the occurrence of first symptoms.

The procedure was performed via the left radial artery with a 7F guide catheter. An initial attempt to cross the lesion with lithotripsy catheter ShockWave IVL 4 × 12 mm (Shockwave Medical Inc., Santa Clara, California, United States), was unsuccessful, therefore rotablation with 1.5 mm burr (Boston Scientific Marlborough, Massachusetts, USA) was performed to facilitate device delivery (Figure 1BC). Afterwards, due to underexpansion of a 3.5 mm NC balloon, lithotripsy was performed (1 × 20 application) (Figure 1D). Before stent implantation, NC balloon TREK Abbott 3.5 × 20 mm was used for predilatation. Two Onyx drug eluting stents (Medtronic, Santa Rosa, California, United States), 3.5 × 38 mm and 4.0 × 34 mm, were implanted. Postdilatation was performed with NC balloons 3.5 × 15 mm and 4 × 20 mm. An optimal angiographic effect with TIMI 3 flow was achieved (Figure 1EF). No adverse events including recurrence of bleeding were noted during hospitalization.

Appropriate lesion preparation is essential for optimal stent expansion and is challenging in heavily calcified lesions. Rotational atherectomy is suitable, in case of NC balloon expansion or IVL balloon delivery failure. IVL can be used for optimization of lesions, when suboptimal balloon or stent expansion is suspected.

Article information


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