If Rotablator is useful, why don't we use it?

manufacturer has produced tapered, more flexible guidewires that straighten arterial contours less and push the burr into the edge of a curve less forcefully. The distal 9 cm of the drive shaft tubing was removed, also making the shaft more flexible. With evolution of the shaft-guidewire system biased cutting is reduced. However, in severely angulated segments such as the takeoff of a left circumflex from the left main coronary artery with an angle > 1200, a more substantial wire (type C or Extra Support) can be preshaped to match the anatomy. This lesion specific prebending provides more complete abrasion of the plaque with decreased deeply biased cutting. Remaining concerns Unfortunately, rotational atherectomy is a demanding technique that requires training and experience to perform with few complications. Praeceptorships and training courses should improve results and acceptance in the future. Cost effectiveness of rotational atherectomy for other than undilatable lesions is yet to be proven, and cost justification will be required before widespread use of rotational atherec-tomy can be expected. The RotaLink system, which provides a detachable turbine and drive shaft with the ability to add extra burrs at a reduced cost, is currently being tested. This system will make the cost of rotational atherectomy more competitive. Debulking is often used in ostial lesions, in diffuse disease, and in calcified segments before stent implantation. Ideally, a debulking device should remove the most calcified and unyielding elements of the plaque, leaving only a soft tissue rim to dilate or stent. The Rotablator should be uniquely suited for these indications, but the lack of confirmatory data from randomised trials, concerns regarding creatine kinase concentrations, and cost issues have hindered widespread use of rotational atherectomy even in these potentially favorable situations. These concerns are valid and can only be answered by carefully conducted clinical trials. Preliminary data suggest that abciximab may reduce post-rotational atherectomy creatine kinase increase," and a randomised trial to address the adjunctive use of abciximab is planned. A trial of rotational atherectomy versus dilatation before stent implantation is beginning, and a trial comparing angioplasty versus rotational atherectomy is underway (Dilation v Ablation Revascularization Trial). Angioplasty has failed to provide longlasting results with diffuse within-stent restenosis, while preliminary data suggest that rotational atherectomy is effective. A randomised trial to establish the appropriate role of rotational atherectomy in this increasingly common clinical situation is planned. Rotational atherectomy is still evolving and is now established …