Abstract
Background
The impact of burr speed on rotational atherectomy (RA) mechanical efficacy remains debated. We aimed to analyze the effect of different RA protocols on postinterventional luminal gain.
Methods
Procedures were performed in vitro on proximal left anterior descending artery with a 1.75-mm burr in a 3-dimensional–printed beating heart model. All lesions first underwent a high speed (HS; 180,000 revolutions per minute) pecking run followed by a HS polishing run of 30 seconds. This standard technique was completed by additional 30-second low speed (LS; 110,000 revolutions per minute) runs as follows: 1 (LS short group, n = 28 lesions); 2 (LS midgroup, n = 30 lesions), or 3 additional LS runs (LS long group, n = 27 lesions), while the control group (n = 27 lesions) received no additional polishing. An additional HS long group in which 3 additional 30-second HS polishing runs were delivered following the initial standard steps was also created (n = 27 lesions). The specimens were analyzed by microcomputed tomography scan to measure the average luminal volume (ALV) and minimal cross-section area.
Results
The baseline lesion ALV and minimal cross -section area were and 128.57 mm3 and 1.56 mm2, respectively. The final ALV was significantly higher in LS short (median, 158.9 mm3 [IQR, 150.0-164.9]), LS mid (median, 156.4 mm3 [IQR, 147.1-167.1]), LS long (median, 157.1 mm3 [IQR, 151.0-166.2]), and HS long groups (median, 156.6 mm3 [IQR, 149.0-169.9]) than control specimens (median, 146.8 mm3 [IQR, 137.5-157.3]: P < .001). These values did not differ significantly between all groups with additional polishing runs. Similar results were observed for MSCA and MSCA gain.
Conclusions
These data suggest that additional polishing runs after standard RA procedure improves the debulked lesion volume, regardless of burr speed.
Keywords: calcified lesions, percutaneous coronary intervention, rotational atherectomy
Introduction
Calcified coronary lesions represent a daily challenge for interventional cardiologists. These lesions regularly require advanced preparation techniques to prevent percutaneous coronary interventions (PCI) pitfalls (such as stent underexpansion or struts malapposition), which trigger subsequent clinical complications.1,2 One such technique is rotational atherectomy (RA), which directly ablates the calcified atheromatous plaque, reduces its volume, and thus improves PCI success rate in complex lesions.3,4 Despite its effectiveness and its strong endorsement by the most recent consensus documents and scientific guidelines,5,6 the adoption of RA remains hampered by the lack of standardization of practices among operators.7
The classical RA technique involves a multiple debulking steps that are performed with a high burr rotation speed, ranging between 150,000 and 190,000 revolutions per minute (RPM).7,8 The use of an RA at lower speed is traditionally associated with a reduced lesion-crossing efficacy and an increased risk of burr stalling.8 However, recent studies (conducted either in vitro or in vivo) have recently explored the possible use of additional RA sequences at lower speeds (<140,000 RPM) and suggested greater efficacy in terms of luminal gain than a conventional strategy.9, 10, 11 The reasons for the potential superior efficacy of this strategy remain hypothetical and debated.10,12 However, the reproducibility of this strategy’s results has to be demonstrated since the potential effect of burr speed variations on the debulking efficacy needs to be clarified. The aim of the present prospective in vitro study was to analyze the effect of different RA protocols on the luminal gain and the amount of material removed during the intervention.
Materials and methods
This study was conceived, designed, and conducted by the French Rotablation Initiative Taskforce (FRIT) investigators. The authors adhered to the relevant ethical guidelines.
In vitro model
In vitro RA procedures were performed in the HEARTROID (Heartroid) model. The model components and global design have been previously described elsewhere.13 This model has a pocket in the proximal left anterior descending (LAD) artery, where the artificial lesion was inserted. The target lesion was designed by 3-dimensional printing and epoxy resin modeling. The tension strength and the Young modulus of elasticity of the material were 60 MPa and 2.73 GPa, respectively. The morphologic specifications of the LAD lesion were as follows: total length, 20 mm; stenosis length, 10 mm; minimum lumen diameter, 1.41 mm; proximal reference diameter, 4.0 mm; distal reference diameter, 2.75 mm; minimal cross-section area (MCSA), 1.56 mm2. The heart rate of the HEARTROID model was fixed at 60 bpm throughout the experiments. This initial pecking and polishing sequence were defined as a standardized reference protocol for experimental comparison and was not intended to reflect all procedural adaptations commonly performed in routine clinical practice.
RA procedures
RA procedures were performed with the ROTAPRO system (Boston Scientific) through a 7F Extra Back Up 3.5 Launcher guiding catheter (Medtronic) inserted in the model left main artery. A ROTAWIRE extra support dedicated guide wire (Boston Scientific) was inserted across the lesion and placed in the distal part of the LAD. A 1.75-mm diameter burr (cross-section area [CSA]: 2.4 mm2) was used for all procedures. A single burr size (1.75 mm) was deliberately used for all procedures to standardize experimental conditions, ensure consistent lesion engagement, and achieve sufficient luminal modification for reliable microcomputed tomography (micro-CT)–based volumetric and cross-sectional analyses.
The RA procedures were performed by 5 different operators using standardized protocols that are depicted in Figure 1. The initial common steps were as follows: (1) initial pecking motion run with burr speed set up at 180,000 RPM during 15 seconds; (2) subsequent polish run performed with 8 round trips across the lesion with the burr at a speed of 180,000 RPM during 35 seconds. Additional polish runs were applied with the burr at a speed of 110,000 RPM during 30 seconds (low speed [LS] short), 60 seconds (LS mid), and 90 seconds (LS long) or with the burr at a speed of 180,000 RPM during 90 seconds (high speed [HS] long). In the control group, no additional polish run was applied. Care was taken to prevent any drop in the rotational speed of 5000 rpm. The low speed setting was defined as 110,000 RPM, as rotational speeds <140,000 RPM are generally considered LS in prior experimental and clinical studies, and 110,000 RPM has been used in published reports evaluating LS polishing runs following conventional HS atherectomy.9,12 The 5 operators performed all types of RA protocols in a randomized fashion. Lesions were allocated to a treatment protocol using block randomization before starting. To control the burr fatigue and avoid biases, each burr was used for 3 consecutive procedures. This parameter was tracked (first, second, and third burr use) for each lesion. Some examples of the Rotablator burr mechanical behavior at different speeds during the polish run through the lesion are shown in Supplemental Videos 1 and 2.
Figure 1.
Global design of the study and RA parameters among groups. CT, computed tomography; HS, high speed; LAD, left anterior descending; LS, low speed; RA, rotational atherectomy; rpm, revolution per min.
Micro-CT scan analysis
The specimens were analyzed after RA procedures by micro-CT scan. All acquisitions were performed using a COMET YXLON FF35CT Micro-CT system (Comet Yxlon). The scan images were exported as floating point VGI volumes and rendered in Volume Graphics VGStudio MAX 3.0 (Hexagon). The images were reviewed by 2 operators unaware of the assigned treatment group.
The rendered lesions were cross-sectioned every 0.1 mm of lesion length (Figure 2). The outlines of lumen were drawn for area measurements on each cross-section by the automatic multiple points trace function and best-fit radius method. The final luminal minimal cross section area (MCSA) was also compared with the baseline lesion MCSA and the burr section area. The roundness of the lumen was assessed by the maximal inscribed circle and minimum circumscribed circle methods, as previously described.14,15 Ovality was calculated as the difference between the minimum circumscribed and the maximal inscribed circles radius. The lesion luminal volume was calculated using the Simpson rule and the different CSA. The absolute luminal gain was calculated as the difference between the luminal volume after and before RA, the latter being measured on an intact specimen and equal to 128.57 mm3. The relative luminal gain percentage was the ratio between the absolute luminal gain and the baseline lesion luminal volume. The interobserver and intraobserver variability of CSA was analyzed in a subset of intact and treated specimens. The CSA variance was equal to 0.11 and 0.06 mm2 in unburred and burred lesions, respectively, suggesting reliable measurement methods. The micro-CT analysis was specifically designed to quantify luminal geometric parameters, including luminal volume, MCSA, and lumen ovality; no surrogate markers of complications such as debris burden, simulated slow-flow phenomena, or distal embolization were assessed.
Figure 2.
Microcomputed tomography scan analysis plan in the specimen: global overview and cross-section parameters. RA, rotational atherectomy.
Statistical analysis
Statistical analyses were performed with SPSS 28.0 (IBM Corp) and PRISM 10.0 (GraphPad Inc) software. Continuous data were expressed in median (IQR). Continuous variables normal distribution was tested by the Shapiro-Wilk test. The differences between the variables among groups were compared by the Kruskal-Wallis test for quantitative variables. All tests were 2-sided and a P value of <.05 was considered statistically significant.
Results
A total of 139 lesions were included in the protocol and displayed in the different groups (Figure 1). All lesions were treated by RA and underwent postprocedural micro-CT scan analysis. The baseline lesion average luminal volume and MCSA were and 128.57 mm3 and 1.56 mm2, respectively.
The post-RA lesion parameters among the different groups are displayed in Table 1 and Figures 3 and 4. The MCSA were significantly larger in the lesions that underwent additional polish runs compared with the ones from the control group (2.9 mm2 [2.6-3.0]), irrespective of the burr speed and procedure duration. However, these parameters were comparable between the LS (LS short (3.4 mm2 [IQR, 3.0-3.8]), LS mid (3.5 mm2 [IQR, 3.1-3.8]), LS long (3.5 mm2 [IQR, 3.2-4.4]), and HS long (3.6 mm2 [IQR, 3.4-4.2]) groups. Moreover, the relative increase in MCSA compared with baseline MCSA was also significantly higher in the LS short (115% (93-142]), LS mid (123% [97-145]), LS long (127% [102-180]), and HS long (129% [116-171]) groups than that in the control group (83% [67-93]; P < .05), with no significant difference between LS and HS long groups. Similar results were observed for the relative increase in MCSA compared with burr section area, the final luminal volume, absolute luminal volume gain, and relative luminal volume gain, with larger volumes in lesions treated by additional polish runs but no difference between the different LS and HS groups (Figure 4).
Table 1.
Post-RA lesion parameter measurements among groups.
| Control group (n = 27) | LS short group (n = 28) | LS midgroup (n = 30) | LS long group (n = 27) | HS long group (n = 27) | |
|---|---|---|---|---|---|
| MCSA, mm2 | 2.9 (2.6-3.0) | 3.4 (3.0-3.8) | 3.5 (3.1-3.8) | 3.5 (3.2-4.4) | 3.6 (3.4-4.2) |
| MCSA increase vs baseline, % | 83 (67-93) | 115 (93-142) | 123 (97-145) | 127 (102-180) | 129 (116-171) |
| MCSA increase vs burr area, % | 19 (9-25) | 40 (25-57) | 45 (28-59) | 47 (32-82) | 49 (40-76) |
| Post-RA average luminal volume, mm3 | 146.8 (137.6-157.3) | 158.9 (150.0-164.8) | 156.4 (147.1-167.1) | 157.1 (151.0-166.2) | 156.6 (149.0-169.9) |
| Absolute luminal volume gain, mm3 | 18.2 (9.0-28.8) | 30.3 (21.4-36.3) | 27.8 (18.5-38.5) | 28.6 (22.5-37.7) | 28.0 (20.4-41.3) |
| Relative luminal volume gain, % | 14.2 (7.0-22.4) | 23.6 (16.7-28.2) | 21.6 (14.4-29.9) | 22.2 (17.5-29.3) | 21.8 (15.9-32.1) |
| Average ovality | 0.05 (0.03-0.08) | 0.07 (0.05-0.14) | 0.09 (0.05-0.16) | 0.10 (0.07-0.20) | 0.13 (0.08-0.23) |
Values are median (IQR).
HS, high speed; LS, low speed; MCSA, minimal cross-section area; RA, rotational atherectomy.
Figure 3.
Postrotational atherectomy lesion minimal cross-section (CS) areas in the different groups. HS, high speed; LS, low speed.
Figure 4.
Postrotational atherectomy lesion luminal characteristics in the different groups. (A) Luminal volume. (B) Luminal gain. HS, high speed; LS, low speed.
We observed an increase in the final lesion luminal average ovality according to the procedure duration. Although, the difference was not significant between control and LS short groups (P = .11), the ovality was significantly higher in the LS mid, LS long, and HS long groups than that in controls. Nevertheless, no significant difference could be, once again, identified between these latter groups.
We did not observe significant effect of the fatigue on burr performances, as the values of the different parameters were comparable in the LS and HS groups in the first, second, and third burr use subgroups (not shown). No burr entrapment was reported in any group (including LS-treated specimen) during the different procedures. Altogether, these results suggested additional positive effect of complementary RA polish runs on final luminal dimensions, irrespective of burr rotational speed.
Discussion
The present study prospectively investigated in vitro the impact of burr speed variations and polish run duration on the debulking efficacy of RA procedures. We observed that additional polish runs increase the debulked lesion volume and final luminal gain and that LS and HS additional RA runs provided similar results (Central Illustration).
Central Illustration.
Effect of low speed and high speed additional polishing runs on microcomputed tomography (micro-CT) scan analyses after left anterior descending artery concentric lesion rotational atherectomy (RA) in vitro. RPM, revolution per minute.
Rotational atherectomy is one of the cornerstones of the management of calcified coronary lesions PCI.5 This technique makes it possible to remove part of the calcified atheroma in situ: preparation of the plaque obtained then makes it easier to deliver stents and achieve its optimal expansion within the lesion.7,8,16 However, the technique requires a learning curve and suffers from a lack of standardization between operators.7 In routine clinical practice, RA is often performed using repeated pecking and polishing passes tailored to lesion response, angiographic appearance, and operator judgment. The question of the optimum burr rotation speed remains a point of debate. The use of high speeds (>150,000 RPM) increases efficacy but has been associated with increased platelet activation and a higher risk of slow-flow phenomenon.17 Conversely, the use of low rotational speeds could minimize this hazard but would expose the patient to an enhanced risk of burr stalling.8,17 The most recent international consensus documents strongly advise against this strategy, except for experienced operators.7 However, recent articles have suggested the increase in debulking efficacy when LS RA runs were used,9, 10, 11 whereas another work did not confirm these findings.12 The superior mechanical effectiveness of LS than that of HS therefore remains hypothetical, and the underlying causes behind it are debated. Hence, Mizutani et al10 advanced that the torque of the burr might be superior at lower speed than that at high speed, increasing thus the outward device efficacy and improving luminal gain. In addition, Yamamoto et al9 suggested that RA device could be subject to vibrations, whose amplitude increases as the rotational speed decreases and thus could create a larger debulking area. Interestingly, this latter point was also identified in our video records comparing LS and HS RA runs. While the concept that additional polishing may improve luminal gain is familiar to experienced operators, the novelty of the present study lies in the objective quantification of luminal volume, MCSA, and ovality using high-resolution micro-CT analysis in a controlled in vitro setting.
In the present study, we report that applying additional RA runs after the initial pecking and polish steps provided extra luminal gain and increased lumen ovality. On the contrary, we also observed a plateau effect for efficacy according to procedure duration and no difference between LS and HS sequences. Several reasons could explain the discrepancies between our data and previously reported results. Our work presents the largest series of lesion treated by RA in a prospective cohort that used standardized protocols to control and minimize the potential variations in procedure parameters. Other previous works were retrospective analyses of monocentric experience over few years of practice, which might have carried out biases (eg, procedures duration, burr size, and lesions dimensions).9,10,12 Moreover, we used micro-CT scan analysis to assess the RA results. This imaging method remains the most accurate modality to identify subtle changes in the specimen structure and allow precise luminal volume and ovality calculations. The other groups used intracoronary imaging, mostly optical coherence tomography, and only focused on MCSA and diameters following RA.9,10,12 In addition, most of the studies investigating LS RA did not analyze the impact of RA duration on results. Hence, Yamamoto et al9 showed that the addition of LS to HS sequences improved lesion minimal diameter in vitro and in vivo, but this strategy was also associated with longer procedures.10,12 Interestingly, the range of RA durations they reported in this study was comparable with the one from our series, advocating for prolonged atherectomy time. Furthermore, the burr size might have also affected the results. Mizutani et al10 suggested that the efficacy of LS atherectomy protocols may be more pronounced when using small burrs (1.25-1.5 mm), where the torque generated may be greater and the debulking effect more pronounced.10 Since we only used 1 burr size (1.75 mm diameter) in these experiments, we could not verify this hypothesis. Burr size may influence debulking efficacy, and the mechanical effects of LS vs HS polishing runs could differ when smaller burrs are used; therefore, the present findings cannot be extrapolated to all burr sizes. Importantly, the present study did not assess the effect of a single prolonged polishing run, but rather the cumulative impact of successive additional polishing sequences applied after the initial standard pecking and polishing steps.
Although our data were generated from the largest set of lesions treated by RA in this experimental setting, our study has several limitations. First, the present study presents data from in vitro experiments using an artificial pulsatile heart model, and its translation to clinical practice needs to be assessed. Moreover, the current experiments were performed in a model of concentric LAD artery lesion. The reproducibility of the results in non-LAD location (right coronary artery and circumflex) and eccentric or nodular lesions remains to be explored. In this latter situation, other parameters, such as the magnitude of the wire bias or the wire mechanical properties (extra support vs floppy), could influence the final result.18 Second, because the present study presents data from in vitro experiments, some procedural aspects might differ from real-life practice. Hence, the tolerance of RA procedures could differ between patients or clinical situations and long (30-second) repeated atherectomy sequences might not be applicable to all cases.7 Although the absolute durations are longer than commonly used in clinical practice, all experimental groups were treated under identical timing conditions for their respective protocols. Long runs ensure measurable luminal modification detectable by micro-CT and to allow precise quantification of the incremental effect of additional polishing sequences. Therefore, the relative comparisons of luminal gain between LS and HS polishing runs remain valid, as the cumulative effect of additional runs was standardized across groups. In addition, the epoxy resin calcification model could differ from the in vivo calcified lesions in term of density and stiffness, which could have influenced the RA process. However, this model has been validated in other atherectomy simulations, and the resin mechanical properties (stiffness and elasticity) are comparable with those observed in human atherosclerotic calcified plaques ex vivo.13,19 Finally, the absence of burr entrapment or performance degradation in the present study contrasts with real-world clinical experience and is likely explained by the controlled in vitro environment. The use of a concentric and homogeneous epoxy resin lesion, the absence of vessel tortuosity, nodular calcification, and guide wire bias, as well as strict adherence to protocolized speed-drop avoidance, likely reduced the mechanical conditions predisposing to burr entrapment. Therefore, the safety profile observed in this model should not be extrapolated to clinical practice. Our findings should therefore be interpreted as a mechanistic and quantitative support of an established clinical practice, rather than as the introduction of a new rotational atherectomy strategy.
In conclusion, these data indicate that the addition of supplemental polishing runs after standard RA procedure improves the debulked lesion volume and lumen ovality, regardless of burr speed in a LAD lesion model. The reproducibility of these results to other models remains to be assessed. Nevertheless, our data advocate for the need of standardized RA procedures and highlight the interest of additional polishing runs following the standard RA.
Declaration of competing interest
Nicolas Amabile, Erwan Bressollette, Benjamin Honton, Benjamin Seguy, and Pierre Deharo report consulting fees from Boston Scientific.
Acknowledgments
Funding sources
This work was funded by an unrestricted educational grant from Boston Scientific.
Ethics statement and patient consent
The authors adhered to the relevant ethical guidelines. No patients were involved in this in vitro study.
Footnotes
To access the supplementary material accompanying this article, visit the online version of the Journal of the Society for Cardiovascular Angiography & Interventions at 10.1016/j.jscai.2026.104397.
Supplementary material
References
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