Orbital Atherectomy: A Comprehensive Review

The safety and efficacy of coronary orbital atherectomy (OA) for treatment of ostial lesions are not yet fully established. We sought to evaluate (OA) treatment of severely calcified ostial and non-ostial lesions.

A retrospective analysis of subjects treated with OA for severely calcified ostial and non-ostial lesions, at the Mount Sinai Medical Center, Miami Beach, Florida (MSMCMB) from January 2014 to September 2020, was completed. Study baseline characteristics, lesion and vessel characteristics, procedural outcomes, and in-hospital major adverse cardiovascular events (MACE) were analyzed and compared.

A total of 609 patients that underwent PCI with OA were identified. The majority of patients (81.9 %) had non-ostial lesions, while 16.6 % had ostial lesions (of which 2.8 % classified as aorto-ostial) and 1.5 % had unknown lesion anatomy. The mean age of the overall cohort was 74.0 ± 9.3 years, and 63.5 % were male. All patients received drug-eluting stent (DES) placement, and the overall freedom from MACE was 98.5 %, with no significant difference observed between the ostial and non-ostial groups. The freedom from cardiac death and MI was also similar between the two groups. There were low rates of bleeding complications and severe angiographic complications, and no persistent slow flow/no reflow was reported.

This study demonstrated no significant differences in in-hospital MACE outcomes between patients with ostial versus non-ostial lesions, indicating that OA is a safe and effective treatment option for both lesion types, including those classified as aorto-ostial.

Coronary artery calcification is prevalent in coronary heart disease with its progression being predictive of future adverse cardiac events. Its presence is considered to be a marker of interventional procedural complexity. Several adjunctive percutaneous coronary intervention tools, such as modifying balloons, atherectomy devices and intravascular lithotripsy, now exist to successfully treat calcified lesions. In this state-of-the-art review, a step-wise progression of strategies is described to modify coronary plaque, from well-recognised techniques to techniques that should only be considered when standard manoeuvres have proven unsuccessful. Technology has advanced greatly over the past few decades and we discuss how future technologies might shape percutaneous intervention.

La calcificación grave está presente en más del 50% de las oclusiones coronarias crónicas totales (OCT) tratadas mediante intervención percutánea. Nuestro objetivo fue describir el uso contemporáneo de los dispositivos de modificación de placa (DMP) en este contexto.

Los pacientes se incluyeron en el Registro Ibérico de OCT de forma prospectiva y consecutiva (32 centros de España y Portugal), de 2015 a 2020. Se compararon en función del uso o no de DMP.

Se incluyó a 2.235 pacientes, en 1.900 de los cuales se logró cruzar con éxito la lesión con guía. Se utilizó al menos un DMP en un 7% (134 pacientes) y más de uno en 24 pacientes (1%). Los DMP seleccionados fueron: aterectomía rotacional (35,1%), litotricia (5,2%), láser (11,2%), balones de corte (27,6%), balones OPN (2,9%) o combinaciones de más de uno (18%). Se utilizaron DMP en pacientes más ancianos, con mayor riesgo cardiovascular y puntuaciones Syntax y J-CTO más elevados. Esta mayor complejidad se asoció con procedimientos más prolongados, pero similar longitud total de stent (52 frente a 57 mm; p = 0,105). Cuando la guía cruzó con éxito la oclusión, la tasa de éxito final del procedimiento fue del 87,2%, pero se incrementó al 96,3% cuando se utilizaron DMP (p = 0,001). Por el contrario, los DMP no se asociaron con mayor tasa de complicaciones en el procedimiento (3,7 frente a 3,2%; p = 0,615). Pese al peor perfil de riesgo basal, a los 2 años de seguimiento no hubo diferencias en la tasa de supervivencia (94,3% DPM frente a no-DMP: 94,3% no-DPM, respectivamente, p = 0,967).

Cuando la guía cruzó con éxito una OCT, la tasa de uso de los DMP fue del 7% y se asoció a una tasa de éxito final del procedimiento significativamente mayor. Los resultados a medio plazo fueron comparables cuando se precisaron DMP pese a su mayor riesgo basal, lo que sugiere que un mayor uso adecuado de estas técnicas en este contexto podría conllevar tanto beneficios técnicos como pronósticos.

Severe calcification is present in > 50% of coronary chronic total occlusions (CTOs) undergoing percutaneous intervention. We aimed to describe the contemporary use and outcomes of plaque modification devices (PMDs) in this context.

Patients were included in the prospective, consecutive Iberian CTO registry (32 centers in Spain and Portugal), from 2015 to 2020. Comparison was performed according to the use of PMDs.

Among 2235 patients, wire crossing was achieved in 1900 patients and PMDs were used in 134 patients (7%), requiring more than 1 PMD in 24 patients (1%). The selected PMDs were rotational atherectomy (35.1%), lithotripsy (5.2%), laser (11.2%), cutting/scoring balloons (27.6%), OPN balloons (2.9%), or a combination of PMDs (18%). PMDs were used in older patients, with greater cardiovascular burden, and higher Syntax and J-CTO scores. This greater complexity was associated with longer procedural time but similar total stent length (52 vs 57 mm; P = .105). If the wire crossed, the procedural success rate was 87.2% but increased to 96.3% when PMDs were used (P = .001). Conversely, PMDs were not associated with a higher rate of procedural complications (3.7 vs 3.2%; P = .615). Despite the worse baseline profile, at 2 years of follow-up there were no differences in the survival rate (PMDs: 94.3% vs no-PMDs: 94.3%, respectively; P = .967).

Following successful wire crossing in CTOs, PMDs were used in 7% of the lesions with an increased success rate. Mid-term outcomes were comparable despite their worse baseline profile, suggesting that broader use of PMDs in this setting might have potential technical and prognostic benefits.

Calcified coronary lesions present a unique challenge for patients undergoing percutaneous coronary interventions (PCI). A higher prevalence of calcific lesions is seen in men and older patients, while diabetes, chronic kidney disease, and tobacco use are significant risk factors. Calcific lesions have been associated with an increased risk of stent thrombosis, restenosis, and major adverse cardiac outcomes (MACE). Larger plaque burden and increased lesion complexity, such as bifurcation or chronic total occlusion, are commonly seen with calcific coronary lesions.

Coronary calcifications lead to increased procedural complexity with difficulty in lesion preparation, balloon delivery and dilation, and stent delivery and expansion. Given the complexity, stent fracture, under expansion, or malapposition of stents lead to unfavorable outcomes such as thrombosis, myocardial infarction, or restenosis. A favorable result with stent implantation is predicted by final minimal stent area (MSA), larger stent areas lead to improved stent patency, achieved by appropriate modification of plaque morphology before stent implantation. Various interventions, such as specialty balloons and atherectomy, have been developed to overcome calcium burden and maximize MSA, thereby potentially improving PCI outcomes. In this chapter, we will focus on nonatherectomy (cutting, scoring, and lithotripsy) and atherectomy (rotational, orbital, and laser) strategies for calcific lesion modification before PCI.

Endovascular treatment of coronary and lower extremity peripheral arterial disease is particularly challenging in patients with heavily calcified vessels. This chapter provides an in-depth review of available coronary and peripheral atherectomy devices, the published evidence supporting their use, and clinical applications.

La calcification sévère des artères coronaires, très souvent sous-détectée, majore la complexité de l'angioplastie. L'athérectomie est l'une des techniques de choix pour la préparation de ces lésions calcifiées avant l'implantation d'une endoprothèse. L'athérectomie orbitale (AO) est une nouvelle méthode ayant prouvé sa sécurité et son efficacité dans la préparation des plaques calciques (études ORBIT I et ORBIT II). L'AO est composée d'une couronne sertie de diamants qui abrase la plaque calcifiée endoluminale par force centrifuge et créée des forces pulsatiles sur la paroi qui vont fracturer les plaques calcifiées profondes situées dans la média. L'AO Diamondback 360™ est composée d'un moteur sur table connecté à un arbre de transmission montée d'une couronne excentrée. Le fil guide coronaire spécifique 0,012’’ en Nitinol (ViperWire™) possède 3 qualités : sa torquabilité, sa facilité de navigation et son support. Par rapport à l'athérectomie rotationnelle, l'AO est associée à un taux plus bas de MACE à 1 an, avec moins de revascularisation du vaisseau cible et un temps de fluoroscopie diminué mais au prix d'un taux majoré de dissection et perforation coronariennes. L'AO est un nouvel outil, très séduisant, sûr et efficace à envisager dans la préparation des plaques coronariennes calcifiées.

Severe coronary artery calcification, too often underestimated, increases the complexity of percutaneous coronary interventions. Atherectomy is one of preferred approach for the preparation of calcified lesions before stent placement. Orbital atherectomy (OA) is a new method that has proven to be safe and effective in the preparation of calcium plaques (ORBIT I and ORBIT II studies). The OA is made up of a crown mounted with diamonds that abrades the endoluminal calcium plaque by centrifugal force and creates pulsatile forces on the wall that fractures the deep calcified plaques in the media. The OA Diamondback 360 ™ consists of a tableside electric powered motor handle connected to a drive shaft mounted with an eccentric crown. The OA specific 0.012" coronary guidewire made of Nitinol (ViperWire ™) has 3 qualities; the torquability, the ease of navigation and the support. Compared to rotational atherectomy, AO is associated with a lower rate of MACE at 1 year, with less revascularization of the target vessel and reduced fluoroscopy time but at the cost of an increased rate of coronary dissection and perforation. AO is a new, quite attractive, safe and effective tool to consider in the preparation of calcified coronary lesions.