In-Hospital and 1-Year Outcomes of Octogenarian and Nonagenarian Patients with Severely Calcified Coronary Lesions Treated with Rotational Atherectomy

Abstract

Introduction

Severely calcified coronary lesions are a common challenge in older percutaneous coronary intervention (PCI) populations. We aimed to investigate in-hospital and 1-year outcomes of octogenarian and nonagenarian patients with heavily calcified coronary lesions treated with rotational atherectomy (RA).

Methods

Patients who underwent RA at our center were divided into two groups: octogenarians/nonagenarians (age ≥ 80 years) (n = 194) and younger counterparts (age < 80 years) (n = 591). Patients presented with acute coronary syndrome, and those treated with bare-metal stents were excluded. At 1 year, major adverse cardiac events (MACE) were investigated as a composite of cardiac death, spontaneous myocardial infarction (MI), or target lesion revascularization (TLR).

Results

In-hospital adverse outcome rates were 10.3% in the octogenarian/nonagenarian group versus 13.5% in the younger group (p = 0.266). Notably, the octogenarian/nonagenarian group had numerically higher in-hospital mortality (2.1% vs. 0.5%, p = 0.067). However, after adjusting for potential confounders, in-hospital mortality did not differ significantly between study arms (adj. HR 3.68; 95% CI 0.69–19.5, p = 0.126). At 1 year, the octogenarian/nonagenarian group was associated with a higher MACE rate (20% vs. 13%, adj. HR 1.78; 95% CI 1.27–2.50, p = 0.001), which was driven mainly by more cardiac deaths (13% vs. 4%, log-rank p < 0.001). Rates of MI (log-rank p = 0.708) and TLR (log-rank p = 0.333) were comparable between both study arms.

Conclusions

RA is feasible in octogenarian and nonagenarian patients, with in-hospital adverse outcomes comparable to those of younger patients. Advanced age remains a strong predictor of 1-year MACE, given its inherently higher mortality.

Graphical abstract available for this article.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40119-026-00445-9.

Key Summary Points

Why carry out this study?

Severely calcified coronary artery disease is highly prevalent in older patients undergoing percutaneous coronary intervention (PCI) and is associated with increased procedural complexity and adverse outcomes, despite advances in calcium-modifying technologies.

Evidence on the safety and effectiveness of rotational atherectomy (RA) in octogenarian and nonagenarian patients remains limited, as this population is underrepresented in clinical studies.

This study investigated whether RA-facilitated PCI in patients aged ≥ 80 years is associated with comparable in-hospital outcomes to younger patients, and how advanced age influences 1-year clinical outcomes.

What was learned from the study?

RA remains a practical and effective adjunct to PCI in patients aged > 80 years, with short-term adverse outcomes that do not differ significantly from those observed in younger cohorts.

Despite RA feasibility in this age group, 1-year cardiac mortality remains higher among octogenarians and nonagenarians.

Comprehensive, structured follow-up and proactive secondary prevention are crucial for improving outcomes for such high-risk patients.

Digital Features

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Introduction

Coronary artery calcification (CAC) is common in patients undergoing percutaneous coronary intervention (PCI), affecting 17–35%, and is expected to rise with the aging of the general population [1, 2]. Calcified lesions complicate PCI, as they can hinder device advancement, resist balloon dilation, and increase the risk of vessel dissection, perforation, and stent failure [1, 3]. Additionally, severe CAC is associated with a higher risk of long-term adverse outcomes [1, 2]. A patient-level pooled analysis of BIOFLOW randomized trials found that patients with moderate-to-severe CAC were associated with increased risk of target-vessel MI at 2 years compared to those with none/mild calcification [4]. Furthermore, in another pooled analysis of 19,833 patients, patients with moderate-to-severe coronary calcification were likely associated with adverse patient-oriented and device-oriented adverse outcomes at 5 years, compared to those with none/mild calcification [5].

Rotational atherectomy (RA) is considered crucial for treating certain severely calcified coronary lesions during PCI. It improves stent expansion and outcomes by modifying calcified plaques, especially in non-dilatable or uncrossable lesions [6]. RA has shown higher strategy success rates than balloon-based plaque-modification techniques [7, 8]. Additionally, it has evolved from aggressive plaque debulking to a more optimized lesion preparation approach using smaller burs to reduce complications [9, 10]. RA has been shown to be beneficial not only in the short-term treatment of heavily calcified lesions but also in significantly reducing revascularization rates compared with modified balloons [11].

In addition to RA, other calcium-modifying technologies have emerged in recent years, including orbital atherectomy [12] and intravascular lithotripsy [13]. All calcium-modification modalities aim to improve lesion compliance and facilitate optimal stent expansion in heavily calcified coronary lesions. Technology selection hinges on lesion traits (e.g., superficial vs. nodular calcium, size), anatomy (e.g., tortuosity, bifurcations), operator expertise, and imaging guidance [2].

PCI in octogenarians is especially challenging due to the frequent presence of CAC and multiple comorbidities. Octogenarians often present with complex multivessel diseases and have a higher prevalence of left main (LM) stem involvement [1, 14]. Inherent frailty and reduced physiological reserve further elevate the risk of complications, including acute kidney injury, which itself complicates PCI clinical outcome [15]. Furthermore, left ventricular dysfunction, often secondary to prior myocardial infarction (MI), is frequently observed in this population and contributes to poorer clinical outcomes [16].

There are limited data on the outcomes of RA in octogenarians and nonagenarians undergoing PCI, as most studies focus on broader age groups [7, 14]. We aim to investigate the in-hospital and mid-term outcomes of octogenarian and nonagenarian patients with heavily calcified coronary lesions undergoing PCI with RA.

Methods

Study Design and Patient Population

We investigated 1163 patients who underwent RA in a single center (Heart Center, Segeberger Kliniken, Bad Segeberg, Germany) between February 2003 and December 2023, which have been consecutively included in our RA registry (The Prospective Segeberg Registry for Rotational Atherectomy in Coronary Lesion/s; ClinicalTrials.gov Identifier: NCT04011527). The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. The present study was approved by the ethics committee of Schleswig–Holstein medical syndicate (IRB reference number: 168-11). All patients included in this study have provided written consent for participation in this local prospective registry and for a systematic follow-up. Patients presented with acute coronary syndrome, and those treated with bare metal stents were excluded. Patients who underwent RA in severely calcified lesions during the observation period were divided into two groups according to age group: octogenarians/nonagenarians (age ≥ 80 years) (n = 194) and younger group (age < 80 years) (n = 591). The study flow chart is shown in Fig. 1. Clinical follow-up was obtained either by on-site clinical visit or scripted telephone interview with the patients or their general practitioners.

Fig. 1.

Study flow chart. PCI percutaneous coronary intervention, RA rotational atherectomy

Procedural Details and Medical Interventions

For all procedures, RA was carried out with the CE-marked Rotablator or RotaPro platforms (Boston Scientific Corporation), as previously described in detail in our institutional experience [7]. In each case, burr size was chosen with the primary goal of modifying the calcified plaque to facilitate subsequent balloon and stent delivery, with an escalating burr strategy used when deemed necessary. A target burr-to-vessel diameter ratio of approximately 0.5 was generally adopted. Rotational speed was maintained between 140,000 and 180,000 revolutions per minute (rpm). During RA, a continuous intracoronary flush containing unfractionated heparin (UFH), nitroglycerin, and verapamil was administered. Before RA, all patients received 325–500 mg of oral aspirin and a loading dose of an oral P2Y12 receptor inhibitor, which was continued for 6 months following the index procedure in all cases. Periprocedural anticoagulation with either UFH or bivalirudin was routinely used. The administration of glycoprotein IIb/IIIa inhibitors and the use of percutaneous mechanical circulatory support —such as an intra-aortic balloon pump or the Impella device (Abiomed Inc., Danvers, MA, USA)—were left to the operator’s judgment. All RA procedures in our cohort were performed via transfemoral access. RA was performed in severely calcified coronary lesions at the operator’s discretion, either as an upfront strategy based on angiographic evidence of heavy calcification or as a bailout approach in lesions that were uncrossable or non-dilatable with conventional balloons.

Endpoint Definitions

In-hospital adverse outcomes were defined as a composite endpoint of residual in stenosis ≥ 30%, persistent slow flow at the end of the procedure, dissection beyond the primary lesion that necessitates stenting, perforation, burr entrapment, death, periprocedural MI, target vessel revascularization or stroke. After 1 year, the major adverse cardiac events (MACE) were investigated as a composite of cardiac death, spontaneous MI, and target lesion revascularization (TLR).

Spontaneous and periprocedural MI were classified according to the Third Universal Definition of MI [17]. Cardiac death was defined as any death attributable to a cardiac cause, as well as unwitnessed death or death of unknown etiology. TLR was defined as any repeat PCI performed within the stented segment or within 5 mm of its proximal or distal edges, or as surgical bypass of the target vessel.

Statistical Analysis

Categorical variables were expressed as counts and percentages, whereas continuous variables were described as mean ± standard deviation (SD) or as median with interquartile range [25th–75th percentiles], according to their distribution. Inter-group differences in continuous variables were assessed using either Student’s t test or the Mann–Whitney U test, as appropriate, and categorical variables were compared using the chi-square test. Fisher’s exact test was applied when expected cell counts were too small for valid use of the chi-square test. Binary logistic regression was employed to evaluate predictors of in-hospital adverse events, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were reported. Given the limited number of in-hospital mortality events, a propensity score-adjusted regression approach was used as a risk-adjustment strategy to control for baseline and procedural differences between age groups. The propensity score was estimated using a logistic regression model including sex, body mass, height, diabetes mellitus, dyslipidemia, glomerular filtration rate, left ventricular ejection fraction (LVEF), presence of type B2/C lesions, chronic total occlusion, bifurcation lesions, use of new-generation drug-eluting stents, and total stented length. The propensity score was then included as a covariate in a multivariate regression model assessing the association between age group and in-hospital mortality. This approach was chosen to mitigate overfitting in the context of sparse outcome events. Results are reported as adjusted associations. The distribution of propensity scores in octogenarian/nonagenarian and younger patients is illustrated in Supplementary Fig. 1. Time-to-event outcomes at 1 year were analyzed using Kaplan–Meier survival curves with log-rank tests for group comparison. One-year clinical endpoints were assessed based on time to first event, summarized as Kaplan–Meier estimates, and further examined using Cox proportional hazards regression, with results reported as hazard ratios (HRs) and 95% CIs. A multivariable Cox regression model was fitted, including all covariates with p < 0.10 in univariable analysis. All p values were two-sided, and a p value < 0.05 was considered statistically significant. Statistical analyses were performed using SPSS version 26.0 (IBM Corp., NY, USA).

Results

Baseline Clinical and Demographic Characteristics

The octogenarian/nonagenarian group was more frequently women (p = 0.022) and individuals with chronic renal insufficiency (p < 0.001). On the contrary, the younger group showed more dyslipidemia (p < 0.001), higher BMI (p < 0.001) and were more frequent smokers (p < 0.001), with family history of coronary artery disease (p = 0.007) and more history of MI (p = 0.009) and coronary artery bypass graft (CABG) (p = 0.030). Further clinical and demographic characteristics were balanced between the two study groups and are summarized in Table 1.

Table 1.

Clinical and demographic characteristics

	Octogenarians and nonagenarian (n = 194 patients)	Younger population (n = 591 patients)	p value
Age, years	83.2 [81.4–85.2]	72.4 [66.5–76.6]	< 0.001
BMI	26.1 [2.8.0–28.8]	27.8 [25.1–30.4]	< 0.001
Female	49 (25.3%)	104 (17.6%)	0.022
LVEF < 40%	26 (13.4%)	75 (12.7%)	0.806
LVEF (%)	55 [47–60]	55 [50–60]	0.194
Coronary disease			0.097
1-vessel disease	21 (10.8%)	82 (13.9%)
2-vessel disease	46 (23.7%)	174 (29.4%)
3-vessel disease	127 (65.5%)	335 (56.7%)
Diabetes mellitus	67 (34.5%)	208 (35.2%)	0.931
Arterial hypertension	177 (91.2%)	534 (90.4%)	0.778
Dyslipidemia	79 (40.7%)	385(65.1%)	< 0.001
Smoking	32 (16.5%)	211 (35.7%)	< 0.001
Family history	26 (13.4%)	132 (22.3%)	0.007
Chronic renal impairment (GFR < 60)	68 (35.2%)	97 (16.6%)	< 0.001
Previous MI	22 (11.3%)	115 (19.5%)	0.009
Previous PCI	69 (35.6%)	243 (44.1%)	0.177
Previous CABG	24 (12.4%)	114 (19.3%)	0.030

Data presented as median and interquartile range or number and percentage

BMI body mass index, CABG coronary artery bypass graft, LVEF left ventricular ejection fraction, MI myocardial infarction, PCI percutaneous coronary intervention

Angiographic and Procedural Characteristics

The amount of contrast dye and procedural time were comparable in both study groups. LM stem stenosis (p < 0.001) and bifurcation lesions (p = 0.048) were more frequent in the octogenarian/nonagenarian group. Additionally, more new-generation drug-eluting stents (DES) (p < 0.001), and smaller burr/artery ratio (p = 0.004), were used in the octogenarian/nonagenarian arm. Further angiographic and procedural characteristics are detailed in Table 2.

Table 2.

Angiographic and procedural characteristics

	Octogenarians and nonagenarian (n = 205 lesions)	Younger population (n = 604 lesions)	p value
Procedural duration (min)	87.5 [59.5–120.5]	237 [58–111]	0.269
Amount of contrast dye	212 ± 93	212 ± 120	0.089
Target vessel
Left main trunk	48 (23.4%)	77 (12.7%)	< 0.001
Left anterior descending coronary artery	86 (42.0%)	286 (47.4%)	0.195
Left circumflex coronary artery	32 (15.6%)	79 (13.1%)	0.411
Right coronary artery	63 (30.7%)	189 (31.3%)	0.931
Bifurcational lesion	96 (46.8%)	234 (38.7%)	0.048
CTO	14 (6.8%)	59 (9.8%)	0.259
B2/C	184 (98.8%)	533 (88.2%)	0.612
Total stent length per lesion	44 [26–62]	40 [24–56]	0.166
Intravascular imaging	43 (23.9%)	130 (28.6%)	0.237
Stents			< 0.001
Early generation DES	35 (17.1%)	178 (29.8%)
New-generation DES	170 (82.9%)	419 (70.2%)
Burr/artery ratio	0.44 [0.43–0.50]	0.5 [0.43–0.55]	0.004
> 1 burr used	34 (16.6%)	71 (11.9%)	0.093
Elective rotablation	146 (71.2%)	395 (65.4%)	0.144

Data presented as mean ± standard deviation, median and interquartile range, or number and percentage

BMI body mass index, CTO chronic total occlusion, DES drug-eluting stent

In-Hospital Adverse Outcomes

The in-hospital adverse outcome rates were 10.3% in the octogenarian/nonagenarian group versus 13.5% in the younger group (p = 0.266). Moreover, the octogenarian/nonagenarian group had numerically higher in-hospital mortality rates (2.1% vs.0.5%, p = 0.067), however, after adjusting for potential confounders, in-hospital mortality rates did not differ significantly between study arms (adj. HR 3.68; 95% CI 0.69–19.5, p = 0.126). Detailed in-hospital adverse outcomes are displayed in Tables 3 and 4.

Table 3.

In-hospital adverse outcomes

	Octogenarians and nonagenarians (n = 194 patients)	Younger population (n = 591 patients)	p value
Residual stenosis > 30%	2 (1.0%)	8 (1.4%)	1.000
Persistent Slow Flow	4 (2.1%)	23 (3.9%)	0.265
Dissection	4 (2.1%)	31 (5.2%)	0.071
Perforation	4 (2.1%)	12 (2.0%)	1.000
Entrapment	0.0%	8 (1.4%)	0.211
Death	4 (2.1%)	2 (0.5%)	0.067
Periprocedural MI	6 (3.1%)	25 (4.2%)	0.671
TLR	0.0%	1 (0.2%)	1.000
Stroke	0.0%	4 (0.7%)	0.577
In-hospital adverse outcomes	20 (10.3%)	80 (13.5%)	0.266

Data presented as number and percentage

MI myocardial infarction, TLR target lesion revascularization

Table 4.

Independent predictors of in-hospital death

	Univariate
	Odds ratio	95% confidence interval	p value
Octogenarians and nonagenarians	4.13	0.92–18.6	0.065
BMI	1.01	0.87–1.18	0.884
Female	0.67	0.08–5.74	0.728
DM	0.74	0.14–3.84	0.720
Dyslipidemia	1.74	0.34–9.01	0.511
LVEF < 40	17.7	3.39–92.5	0.001
Renal impairment	2.82	0.63–12.72	0.178
Bifurcational lesion	1.07	0.24–4.80	0.932
CTO	1.69	0.20–14.20	0.631
Total stent length	1.02	0.99–1.04	0.182

Propensity score-adjusted regression multivariate analysis
	Adjusted odds ratio	95% confidence interval	p value
Octogenarians and nonagenarians	3.68	0.69–19.53	0.126

BMI body mass index, CTO chronic total occlusion, DM diabetes mellitus, LVEF left ventricular ejection fraction

Clinical Outcomes After 1 Year

At 1-year follow-up, the octogenarian/nonagenarian group was associated with more frequent MACE rates (20% vs. 13%, HR 1.74; 95% CI 1.14–2.65, p = 0.010), driven mainly by higher rates of cardiac death (13% vs. 4%, HR 3.84; 95% CI 2.12–6.99, p < 0.001). On the other hand, rates of MI (2% vs. 2%, HR 1.29; 95% CI 0.34–4.85, p = 0.709) and TLR (6% vs. 8%, HR 0.69; 95% CI 0.32–1.47, p = 0.337) were comparable between study arms (Fig. 2).

Fig. 2.

Kaplan–Meier curves for the cumulative incidence of MACE (composite of cardiac death, MI, or TLR). MACE major adverse cardiac events, MI myocardial infarction, TLR target lesion revascularization

In a multivariate analysis, the octogenarian age group emerged as an independent predictor of 1-year MACE (adj. HR 1.78; 95% CI 1.27–2.50, p = 0.001), along with chronic renal insufficiency (adj. HR 1.70; 95% CI 1.19–2.41, p = 0.003), total stent length (adj. HR 1.01; 95% CI 1.00–1.01, p = 0.009) and in-hospital adverse outcomes (adj. HR 2.02; 95% CI 1.35–3.03, p = 0.001). Higher LVEF was protective against 1-year MACE (adj. HR 0.98; 95% CI 0.97–0.99, p = 0.015) (Table 5).

Table 5.

Independent predictors for 1-year MACE

	Univariate			Multivariate
	Hazard ratio	95% confidence interval	p value	Hazard ratio	95% confidence interval	p value
Octogenarians and nonagenarians	1.74	1.14–2.65	0.010	1.78	1.27–2.50	0.001
Female	0.75	0.43–1.30	0.304
BMI	0.99	0.95–1.03	0.627
DM	1.02	0.67–1.54	0.935
Dyslipidemia	1.18	0.78–1.77	0.444
Multivessel disease	2.43	1.07–5.56	0.035	1.40	0.79–2.48	0.253
LVEF (continuous variable)	0.98	0.97–0.99	0.030	0.99	0.97–0.99	0.015
Renal impairment	1.78	1.15–2.76	0.009	1.70	1.19–2.41	0.003
Bifurcational lesion	1.03	0.69–1.54	0.883
CTO	1.63	0.87–3.06	0.126
Total stent length	1.01	1.01–1.02	0.018	1.78	1.27–2.50	0.009
New-generation DES	0.85	0.55–1.31	0.467
In-hospital adverse outcomes	2.34	1.46–3.77	< 0.001	2.02	1.35–3.03	0.001

BMI body mass index, CTO chronic total occlusion, DES drug-eluting stent, DM diabetes mellitus, LVEF left ventricular ejection fraction, MACE major adverse cardiac events

Discussion

The main findings of the present analysis can be summarized as follows:

1. RA is feasible in octogenarian and nonagenarian patients, with acute in-hospital adverse outcomes non-significantly different compared to those in the younger population.

2. Advanced age remains a strong predictor of 1-year MACE due to inherently higher mortality rates.

Understanding the safety and efficacy of RA in octogenarian and nonagenarian patients is increasingly relevant, with the global trend of an aging population. To the best of our knowledge, this is the largest study to investigate acute, and mid-term clinical outcomes of RA-facilitated PCI in an octogenarian/nonagenarian population.

The octogenarians/nonagenarians in our study demonstrated a significantly higher burden of comorbidities. These characteristics reflect the well-documented challenges associated with advanced age and align with previous reports underscoring the complexity of coronary disease in this population [18, 19].

Despite clinical challenges in this age group, we found in-hospital adverse outcome rates not significantly different compared to younger patients, consistent with findings from multicenter registries and observational studies reporting procedural success rates exceeding 90% in older populations undergoing PCI with RA [20, 21]. In our analysis, the in-hospital mortality rate was numerically higher in the octogenarian/nonagenarian group; however, the difference was not statistically significant after adjustment for clinical confounders. Notably, in-hospital mortality events were infrequent, and despite the use of a propensity score adjusted multivariate regression, the adjusted estimate showed wide confidence interval, reflecting considerable uncertainty. Therefore, the absence of statistical significance in our case should not be interpreted as proof of no difference; larger studies are needed to more precisely quantify short-term safety in this population.

Advanced age per se was not found to significantly increase PCI procedural risk if patients were carefully selected and treated with contemporary techniques [22]. This is also in line with current literature demonstrating acceptable overall safety of RA in older patients, with major complications such as coronary perforation or acute vessel closure reported in < 2% of procedures [23]. Moreover, elective RA and operator experience were found to contribute to improved procedural efficiency and outcomes in this high-risk population [24]. RA in our analysis was used electively in 66.9% of the whole study population.

Our findings are also consistent with reports from a high-volume center demonstrating similar in-hospital and 1-year outcomes in generally high-risk patients (low LVEF, prior CABG, higher admission glucose level, and higher EuroSCORE II and Syntax Score) undergoing RA, compared with low-risk patients [25].

Although procedural success is achievable in advanced age as previously reported, long-term outcomes remain influenced by baseline clinical status and comorbidities [26, 27]. At 1-year follow-up, we found that the rate of MACE was significantly higher among octogenarian/nonagenarian patients, mainly driven by increased cardiac mortality. This could be linked to abundant clinical comorbidities in the octogenarian/nonagenarian cohort that are known to be associated with increase death rates [27]. Moreover, the more frequent LM disease and/or bifurcation lesions may add to the mortality risk [28, 29]. It is worth mentioning that advanced age is generally considered as the strongest risk for cardiac mortality [30, 31]. In our analysis, spontaneous MI and TLR rates were comparable between study groups. The absence of excess TLR argues against late RA- or stent-related complications as the dominant mechanism, particularly given the predominant use of new-generation DES and a uniform RA strategy across groups. These findings suggest that long-term outcomes in octogenarian and nonagenarian patients undergoing complex PCI may be more strongly influenced by underlying comorbidity and disease progression than by procedural factors alone, underscoring the need for intensified post-discharge surveillance and tailored secondary prevention strategies [32].

While data on completeness of revascularization were not systematically collected, the feasibility and clinical benefit of more aggressive or alternative revascularization strategies in older patients remain uncertain. Moreover, hybrid approaches or surgical revascularization are often not options in this population due to advanced comorbidity and prohibitive surgical risk [18, 19].

Managing older patients with CAC requires careful, tailored approaches [3, 4], including detailed pre-procedural assessment and frailty evaluation, as well as treatment in experienced centers [2]. The focus should extend beyond survival to improving symptoms and quality of life, balancing procedural efficacy with minimizing complications to optimize outcomes in this vulnerable group [2, 32].

Clinical Implications

The present study reinforces the notion that RA is a viable adjunctive strategy for PCI in octogenarians and nonagenarians, with procedural and in-hospital outcomes non-significantly different compared to younger patients. However, our data also highlight the ongoing challenge of long-term elevated cardiac mortality. This underscores the importance of individualized risk assessment, especially in patients with significant renal dysfunction, LM disease, or frailty—factors that may compound long-term risk regardless of procedural success. Furthermore, our findings support the need for comprehensive follow-up strategies and potentially more aggressive secondary prevention in this cohort. Interventions such as tailored cardiac rehabilitation, vigilant monitoring for heart failure and arrhythmias, and close management of comorbidities may play an essential role in improving long-term prognosis.

Study Limitations

This study is subject to some limitations. First, its retrospective design inherently introduces biases and confounding factors that cannot be fully controlled. As age defines the exposure groups, the propensity score was used as a risk-adjustment tool for in-hospital mortality rather than a causal balancing mechanism; therefore, the reported estimates represent conditional associations rather than the total causal effect of age. The low number of outcome events may limit statistical power despite the use of an adjustment strategy. Second, the study cohort was clinically heterogeneous, encompassing a broad spectrum of diagnoses and varying clinical presentations. Nonetheless, this reflects real-world clinical practice. Third, the study spanned over a long period of time, during which substantial advancements occurred in PCI technologies, procedural techniques, and operator experience. However, this temporal evolution was paralleled by increasing disease burden and lesion complexity. Despite these limitations, the large patient cohort was intended to assess the feasibility, safety, and efficacy of RA in very high-risk octogenarians under real-world conditions.

Conclusions

RA is feasible in octogenarian and nonagenarian patients, with in-hospital adverse outcomes non-significantly different compared to younger counterparts. Advanced age remains a strong predictor of 1-year MACE due to inherently higher mortality rates. These findings contribute to the growing body of evidence supporting RA as a feasible revascularization strategy in older patients, while also calling attention to the importance of a multidisciplinary approach to post-procedural care in this vulnerable population. Larger studies are needed to quantify short-term RA safety in patients older than 80 years.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contributions

Concept and design were implemented by Mohamed Samy, Ahmed Alali Allali, and Nader Mankerious, and data collection was performed by Mohamed Samy and Ahmed Alali. Statistical analysis was performed by Nader Mankerious and Mohamed Samy. Manuscript Drafting: Felix Hofman, Oleg Schiopu, Danial Amoey, Karim Elbasha, Martin Landt and Arief Kurniadi. Manuscript revision and editing: Gert Richardt, Abdelhakim Allali, Ralph Toelg, Mohammed Saad, Derk Frank, Stephan Fichtlscherer, and Holger Nef.

Funding

No funding or sponsorship was received for this study, digital features, or publication of this article.

Data Availability

The de-identified participant data will be shared on a request basis. Please directly contact the corresponding author to request data sharing.

Declarations

Conflict of Interest

Nader Mankerious received speaker’s honoraria from Biotronik and Boston Scientific, consulting honoraria from Boston Scientific. Gert Richardt has received institutional research grants from St. Jude Medical, Biotronik, and Medtronic. Gert Richardt is an Editorial Board member of Cardiology and Therapy. Gert Richardt was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions. Ralph Toelg has received speakers’ honoraria from Biotronik. Mohamed Samy, Ahmad Alali, Oleg Schiopu, Karim Elbasha, Felix Hofmann, Abdelhakim Allali, Mohammed Saad, Danial Amoey, Derk Frank, Martin Landt, Arief Kurniadi, Stephan Fichtlscherer, and Holger Nef have no relevant financial or non-financial interests to disclose.

Ethical Approval

Data from this work were derived from a prospective registry (The Prospective Segeberg Registry for Rotational Atherectomy in Coronary Lesion/s; ClinicalTrials.gov Identifier: NCT04011527). The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. The present study was approved by the ethics committee of Schleswig–Holstein medical syndicate (IRB reference number: 168-11). All patients included in this study have provided written consent for participation in this local prospective registry and for a systematic follow-up.