Usefulness of Rotational Atherectomy in the Current Era

We have read with interest the study written by Arora et al about the utilization of rotational atherectomy (RA) in the United States. The investigators have developed a methodologically exquisite analysis, but we believe that the study might drive to the misconcept that RA does not add any advantage to balloon angioplasty before stent implantation. Although RA carries higher costs, takes longer time, and requires high expertise, all these inconveniences are counterbalanced with the undoubtful advantages of this technique in selected cases. The work is focused on a comparison between the cases with and without RA in the Nationwide Inpatient Sample database of 2012 and although we believe that the demographic characteristics are always necessary to describe the population and even the Charlson Co-morbidity Index might be of certain utility to categorize better the patients, in our opinion when an intervenionalist decides if the RA is necessary in a concrete patient these mentioned variables are not of interest and the decision is always based in anatomical issues. We miss in Arora's study variables such as vessel calcification, lesion length, vessel tortuosity, or the support of the guiding catheter. Although the number of cases with RA diminished in the last years of the era of the bare-metal stents due to the improvement in the stent profiles and the high restenosis rate in long lesions, the drastic reduction of this adverse event with the drug-eluting stents in long lesions motivated a progressive increase in the number of cases. Besides this fact, the also progressive increment in the proportion of elderly patients with its associated vessel calcification makes this device even more necessary. In the Spanish Cardiac Catheterization and Coronary Intervention Registry in 1994, a total of 305 cases of RA were performed in 21 centers, and this number reached its minimum in 2003 with 349 cases in 26 centers. However, since that moment and coinciding with the advent of the drug-eluting stents the number of cases has experienced a dramatic increase up to 1,251 cases in 71 hospitals in 2014, representing an increment of 358% and 273% in the number of cases and centers in comparison with 2003. Finally, although it is unquestionable that RA is associated with higher levels of postprocedural biomarkers in comparison with balloon angioplasty, its clinical significance should be put into perspective in relation with its advantages in selected cases and in this way, we should keep in mind that the new definition for “clinically relevant myocardial infarction” proposed by the Society for Cardiovascular Angiography and Interventions states that a clinically relevant type 4a myocardial infarction should be diagnosed by a new biomarker elevation of creatine kinase-MB to ≥10 times the upper limit of normal (ULN) or cTn (I or T) to ≥70 × ULN. In conclusion, far from the idea of being an unnecessary tool associated with adverse events, we believe that this device should be present in all the cath laboratories because it can make possible an impossible case when the wire crosses the lesion, but no other device is able to advance and also it may make easier a challenging case with a long-calcified lesion.