Rotational Atherectomy in the Era of Cost Containment

Dear Editor:

Interventional cardiologists are frequently asked to reduce procedural costs, and devices that are initially thought to be more expensive can sometimes reduce overall costs. Rotablation is technically more demanding and more expensive than traditional angioplasty;  therefore, our center started using rotablation in cases where a balloon could neither cross the lesion nor achieve a proper dilatation.¹ As we became more experienced with rotablation technique, our physicians discovered that there are additional cases appropriate for direct Rotawire (Boston Scientific) and rotational atherectomy, and the technique significantly reduces the length of the procedure and the amount of devices required. This letter discusses the cost savings in two interesting cases.

Case #1. The first patient was a 72-year-old Caucasian male who presented with syncope. His list of previous conditions included permanent atrial fibrillation, asbestosis, duodenal ulcer, polymyalgia rheumatica, and stage-III chronic kidney dysfunction. He looked frail for his age, was not diabetic, and had a history of smoking. His blood tests revealed normal cardiac enzyme levels, with an initial creatinine of 143 µmol/L, hemoglobin of 13.7 g/dL, hematocrit of 40.5%, moderate renal dysfunction (MDRD estimated glomerular filtration rate of 46.8 mL/min), and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) of 1610 ng/L. Electrocardiogram (ECG) on admission showed atrial fibrillation and right bundle branch block (RBBB) with marked left axis deviation. As such, a full work-up for the etiology of his syncopal episode and possible indication for permanent pacing was requested. Findings on transthoracic echocardiogram were preserved left ventricular (LV) function with no regional wall-motion abnormalities, hypertrophy of the basal septum, moderate biatrial dilatation, marked mitral annulus calcification, raised mitral flow velocities with a mean gradient across the mitral valve of 2 mm Hg, mild mitral regurgitation, and mild tricuspid regurgitation, allowing a pulmonary artery pressure estimation of 28 mm Hg. Transesophageal echocardiogram (TEE) showed images suggestive of thrombus in the left atrial appendage and spontaneous contrast in the atrium. Moderate mitral regurgitation was also observed during TEE. There was a suggestion of impaired LV function in contrast with the transthoracic assessment. As such, coronary angiogram was requested.

Coronary angiography was performed using right radial access, 5 Fr sheath, and JL 3.5 and JR 4 diagnostic catheters. The left coronary artery showed atheromatous disease, with non-significant distal plaque in the left main extending into the left circumflex ostium and 50% lesion of the obtuse marginal branch. The right coronary artery (RCA), however, had a long, densely calcified tandem lesion along the entire mid-segment. There was a 75% ostial lesion and virtual occlusion at the mid-segment (99% with TIMI-1 flow to the distal vessel) (Figure 1) with retrograde filling from the left coronary (Rentrop 3).  

Case #2. The second patient, a 62-year-old Caucasian male, was referred to our cardiology clinic due to frequent ventricular ectopic beats. He had a 5-year history of diabetes and was on oral antidiabetic treatment. The patient also suffered from obesity (body mass index, 31.7) and hypertension, but had preserved renal function (MDRD estimated glomerular filtration rate of 99 mL/min). His initial work-up included ECG, which showed sinus rhythm, ventricular trigeminy, and slight depression of ST V5-V6 (0.5 mm). ECG also showed ventricular dimensions in the upper limit of normal, absence of regional wall-motion abnormalities, and normal LV systolic function with diastolic dysfunction. Twenty-four hour Holter monitoring showed permanent sinus rhythm (41 to 87 beats/min, average heart rate of 64 beats/min), incomplete right bundle branch morphology, very frequent ventricular dimorphic ectopics, five couplets, and no runs of ventricular tachycardia. The patient was referred for cardiac multislice computed tomography (CT) to rule out coronary artery disease. The patient’s calcium score of 3223 AU suggested that invasive coronary angiography was necessary.

Coronary angiogram confirmed the presence of coronary artery disease and densely calcified coronary arteries. The left main artery had no significant narrowing, the left anterior descending artery showed two intermediate lesions (one in the mid-segment and another more distal, regarded as non-significant). The left circumflex was unremarkable. There was a 99% lesion (Figure 2) in the proximal segment of the RCA that caused significant impairment in flow (TIMI 1). Retrograde filling from the left coronary artery was present. 

Procedure. Case #1 was performed via the right radial artery using a 6 Fr Amplatz Right 1 guiding catheter. The lesion was crossed with a Fielder XT wire (Asahi Intecc) with the support of a Ryujin 1.5 x 20 mm balloon (Terumo Corporation). Although the balloon crossed the lesion, it burst immediately upon inflation under rated burst pressure. A 2.0 x 20 mm MiniTrek balloon (Abbott Vascular) also crossed the proximal segment of the lesion and burst at 14 atm. Three different compliant balloons of increasing size – 2.0 x 20 mm MiniTrek, 2.5 x 15 mm Apex (Boston Scientific), and 3.0 x 15 mm Trek – were used to prepare the lesion. A Tsunami stent (Terumo Corporation) was advanced, but it failed to reach the more distal RCA region of the mid-segment, as intended, and was expanded at the mid-RCA. After further dilatations with a Trek 3.0 x15 mm balloon, a second 3.5 x 23 mm Tsunami stent was advanced through the first stent. Unfortunately, it disengaged from the balloon and had to be expanded in situ (stent-in-stent). Using a buddy-wire technique with a PT moderate support guidewire (Boston Scientific), a 2.0 x 6 mm Flextome cutting balloon (Boston Scientific) was advanced and inflated distal to the stents. After additional inflations of the compliant 3.0 x 15 mm Trek balloon and further pushing, a 3.0 x 23 mm Tsunami stent was correctly positioned distally, at the expense of a small proximal dissection that was covered with a fourth stent (Integrity; Medtronic). The results were optimized with postdilatations with non-compliant balloons (4.0 x 15 and 4.0 x 8 mm Quantum balloons; Boston Scientific); we achieved a very good final result (Figure 3). A total of 130 mL of contrast were used during the procedure. Twenty-four hours post procedure, creatinine had decreased to 113 mmol/L, potassium was 3.7 mmol/L, high-sensitive troponin I was raised slightly to 0.401 (normal range, <0.034 ng/mL), and myoglobin 44 ng/mL (normal range, 10-92 ng/mL). The patient completed 1 month of dual-antiplatelet treatment and was started on oral anticoagulation after the procedure. A 24-hour Holter monitoring performed 3 months later excluded significant bradyarrhythmia and pauses. At 18-month follow-up exam, the patient remained angina free, with good quality of life. There were no further syncopal episodes.

Case #2 was performed electively via the femoral artery using a 7 Fr Judkins Right 4 guide catheter. Intravascular ultrasound (IVUS)-guided rotational atherectomy followed by stenting was the chosen strategy. A Rotawire easily crossed the very tight lesion with the support of a 1.5 mm Ryujin balloon. Staged atherectomy with a 1.25 mm burr followed by 1.75 mm burrs was performed using the pecking technique. A 3.0 x 20 mm Trek balloon was inflated at low pressure (4-6 atm). Two long drug-eluting stents (3.5 x 24 mm and 4 x 38 mm Promus Element stents; Boston Scientific) were delivered and covered the entire mid and proximal segments of the RCA. Optimization was performed with postdilatation with a non-compliant Voyager balloon (Abbott Vascular). A very good final result was achieved (Figure 4). Post procedure, hemoglobin was 14.4 g/dL, Hematocrit was 42.8%, creatinine raised slightly from 74 to 97.5 mmol/L (normal, < 110 ng/mL), and troponin I was 0.249 ng/mL. Twenty months later, the patient was asymptomatic and no further revascularization has been required. Table 1 lists the devices used and the costs at that date in our catheterization laboratory, as well as the fluoroscopy time for each case. Case #1 required ten different devices and cost ?5492.5. Case #2 required six different devices and cost ?5976.15.

Discussion

Although anecdotal, these cases reflect real life. It is not always easy to predict all the parameters in percutaneous coronary intervention, especially when trying to anticipate the best and most cost-effective treatment option. If we leave the price of devices aside, the second procedure took much less time and was less complicated, which also reflects upon increased patient safety. 

Any cost savings obtained in Case #1 were minimal compared with the complications that were encountered. Case #1 offered a monetary savings of ?483; however, it required almost twice the number of interventional devices. Many of these devices were used due to poor lesion access and complications. Case #2 was an equally challenging case, but potential complications were avoided by adequately preparing the lesion prior to intervention. Additionally, much of the cost incurred in Case #2 was from selecting two different Rotalink burr sizes and this expense may decrease as additional lesion preparation devices or burr sizes become available. 

The radiation exposure was not quantified because the patients had considerable differences in body mass index and this is a very important determinant of radiation dose. However, there was a 25% lower fluoroscopy time in the rotablation case, even having performed additional IVUS.

The debulking ability of rotablation facilitates deliverability of longer stents and enables easier expansion.² All of these facilitate a more satisfying final result, both immediately and in the long term. 

We regard these two cases as good examples of how rotational atherectomy can make a complex intervention run smoothly at a similar cost but with fewer complications. The classic approach proved very expensive in wires, balloons, time, and concern.

References

1. Seca L, Cação R, Silva J, Mota P, Costa M, Leitão Marques A. Rotational atherectomy in the drug-eluting stent era: a recent single-center experience. Rev Port Cardiol. 2012;31(1):1-6. 
2. Cavusoglu E, Kini AS, Marmur JD, Sharma SK. Current status of rotational atherectomy. Catheter Cardiovasc Interv. 2004;62(4):485-498.

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From ¹William Harvey Hospital, East Kent Hospitals Foundation Trust, United Kingdom; ²Cardiovascular Intervention Unit of the Coimbra University Hospital Centre, Coimbra, Portugal; and ³Instituto do Coração, Maputo, Mozambique.

Address for correspondence: Paula Mota, MD, 14 Cossington Road, CT1 3HU, Canterbury, Kent, United Kingdom. Email: paulapmota@gmail.com