Thank you mja! Absorbing mja! Able mja! Billowy mja!
I pick now. Some say I may pick twice. This could be true. I hope it isn't, because I only have a single pick planned out right now and that leaves me in quite the conundrum. Hmm. Well, picking in such a historic phase is a big deal. And I should like to say a few words to mark the occasion:
Rotational atherectomy (RA) is an established tool in interventional cardiology for treatment of calcified coronary lesions. Over 3 decades of clinical experience and research, techniques have matured and outcomes have improved. Heterogeneity exists, however, in RA utilization and technique. We assembled a group of experienced RA operators and device experts to summarize and critique key elements of contemporary RA technique, to identify areas of consensus and controversy, and to offer recommendations for optimal performance for the practicing interventional cardiologist. Evolution in RA strategy toward a focus on lesion modification to facilitate balloon angioplasty and stenting has underpinned major advances in procedural safety, including opportunity to use smaller caliber equipment and radial access. Optimal technique and improved safety have permitted exploratory use of RA for different lesion types and reevaluation of procedural requirements, including flush solution composition and transvenous pacing. Preparedness to manage complications remains paramount and recommendations for operators and institutions are outlined.
Rotational atherectomy (RA) is an endovascular procedure to ablate atherosclerotic plaque by forward advancement of a rotating abrasive burr. The Rotablator Rotational Atherectomy System (
Figure 1; Boston Scientific, Natick, MA) has been commercially available for use in the coronary arteries for the past 3 decades.
1 Over this time, RA has matured as a tool for management of calcified coronary lesions, with additional advances in design accompanying the new RotaPro system (
Figure 2; Boston Scientific, Natick, MA). Yet utilization and practice vary widely, with use of RA varying from <1% to >10% at select centers.
2 Incremental experience has revealed best practices associated with efficacy and safety. Recently, European experts put forward a consensus document on RA technique.
3 Over a series of 4 meetings, a group of experienced North American RA physician operators and industry device experts sought to summarize and critique RA practices. This document represents a collective effort of this multidisciplinary group to provide a contemporary scientific review of key areas of consensus and controversy pertinent to selection of patients and lesions, safe and effective technical performance, and qualification of performing operators and centers.
One in 5 patients undergoing percutaneous coronary intervention (PCI) exhibits moderate or severe coronary artery calcification.
4 Coronary calcification increases technical difficulty of PCI. Accumulated mineral content in calcified plaque complicates delivery and expansion of angioplasty balloons and stents, increases risks of procedural complications including stent underexpansion, asymmetrical expansion, and malapposition, and increases postprocedural complications including restenosis and thrombosis.
5–8 For severely calcified lesions, even high-pressure inflation of a noncompliant balloon may fail to dilate a stenosis despite angiographic appearance of complete balloon expansion.
9 Asymmetrical calcification predisposes to dissection
10 or perforation.
11 Friction from calcification impedes device advancement and wire manipulation.
Patients undergoing PCI for calcified lesions experience a high rate of major adverse cardiovascular events,
12 including in the contemporary drug-eluting stent era. For example, in postmarketing surveillance of everolimus-eluting stents, moderate to severe lesion calcification was associated with a higher rate of ischemia-driven target vessel revascularization (5.8 versus 3.1%;
P=0.025) and major adverse cardiac events (10 versus 5%;
P=0.0011) at 3 years.
13 Both lesion and patient factors may contribute to this association.
14 Intimal calcification correlates with comorbidities including advanced age, diabetes mellitus, and chronic kidney disease.
15 Extent of coronary artery calcification is predictive of systemic atherosclerosis burden, adverse coronary events, and also adverse peripheral vascular and cerebrovascular events.
16
The primary rationale for use of RA is to modify physical attributes of calcified plaque to facilitate balloon angioplasty and stent deployment. This notably reflects a shift in emphasis from an earlier objective to debulk plaque before or in lieu of balloon angioplasty. Two randomized controlled trials inform the current approach. The STRATAS (Study to Determine Rotablator and Transluminal Angioplasty Strategy) compared outcomes of an aggressive strategy (maximum burr:artery ratio >0.70 alone or with adjunctive balloon inflation ≤1 atm) and a routine strategy (maximum burr:artery ratio ≤0.70 with routine balloon inflation ≥4 atm).
17 Aggressive strategy yielded no advantages for clinical success, final minimum lumen diameter, or residual stenosis, and higher rates of periprocedural creatine kinase-myocardial band release and target lesion revascularization at 6 months. The CARAT (Coronary Angioplasty and Rotablator Atherectomy Trial) also showed no benefit with aggressive strategy for procedural success or target vessel revascularization at 6 months, and indeed found higher risk of angiographic complications with a larger burr:artery ratio.
18 Transition in RA practice away from aggressive debulking has permitted use of smaller burrs, sheaths, and guide catheters with improved safety and equivalent efficacy.
There. That was a good speech. One of my best. It is now time. The time for picking. No more waiting. We go NOW
Team Retro Fashion Item:
RAPIER
Once upon a time, people carried swords. It was what you did. Dueling was illegal, and yet often one thing would lead to another and you'd find yourself in a f***ing swordfight. This was a possible outcome of any day for a lot of dudes, like getting stuck in traffic now. And so it was common for men of status (or who aspired to it) to carry swords as part of their everyday dress. Swords became a part of fashion, and were often decorated as such. The rapier is an interesting evolution, because its hand guard was routinely inherently stylish as well as fully functional, meeting both roles of the weapon with ease. Even an unadorned rapier could have an eye catching guard, whether it be the swept-hilt variety or a simpler cup. Owners routinely had them engraved or decorated. Being able to afford a sword was a statement of your own standing; and they were often made into a fashion statement as well. Look at this fashionable thing:
That is, as the tubular youth of today say, "lit banging yeet."
Another example:
And finally, this is Metal As f*** a solid 4 centuries before "Metal" even existed, truly ahead of its time:
Alright me, we are up again. Hurry up and think of something.
