Rotational atherectomy in the era of drug-eluting stents.

Atherosclerosis is one of the most significant underlying problems that can affect patients with cardiovascular disease. In the most serious situations, this condition affects blood supply to the heart or brain, resulting in heart attack, stroke, or sudden cardiac death. In 1977, Andreas Gruentzig performed the first percutaneous transluminal coronary angioplasty (PTCA), a less invasive method for treating obstructive coronary artery disease. However, soon after Gruentzig showed that PTCA was viable, the procedure was only undertaken when focal noncalcified lesions in the proximal coronary arteries were targeted, in an attempt to avoid serious complications such as abrupt vessel closure from intimal dissection, elastic recoil of the artery, and restenosis. In addition to these complications, the inability to dilate certain types of coronary lesions, particularly heavily calcified lesions, is another major limitation of PTCA. Before the bare metal stent (BMS) era, the search for therapeutic strategies to overcome these PTCA limitations was based on animal studies, which showed that severe injury induced a stronger healing response of the treated vessel. Angiographic analyses have revealed that the degree of late restenosis was directly proportional to the acute gain of luminal diameter achieved from angioplasty treatment, and that the proportion between late loss and acute gain was consistent for different interventional devices. Based on these observations, the mechanical approach to plaque excision was supposed to lower the restenosis rate and improve clinical outcomes. Percutaneous coronary rotational atherectomy (PTCRA) was developed in the late 1980s as a debulking device used to facilitate the removal of plaque. Compared to arterial stretching and plaque fracture as seen in PTCA, PTCRA increases the luminal diameter by debulking atherosclerotic plaques with the aid of an abrasive diamond-coated burr. Using routine atheroablation during percutaneous coronary intervention (PCI) is theoretically beneficial; however, clinical evidence from randomized control trials challenges this hypothesis. The rotational atherectomy and conventional balloon angioplasty (DART) comparison study, which has been widely cited for its use of PTCRA in noncomplex lesions in smaller coronary arteries (<3.0 mm), did not demonstrate a different procedural success rate or postprocedure residual stenosis rate between PTCA using adjunctive PTCRA and PTCA alone at 12 months. For complex coronary artery lesions, the excimer laser, rotational atherectomy, and balloon