[Rotational atherectomy in the drug-eluting stent era: the revival of a forgotten technique?].

Although rotational atherectomy (RA) was first introduced in 1986 as a technique for mechanical thrombectomy,1 it was its potential to reduce barotrauma and hence restenosis that sparked the interest of researchers.2--6 Unlike balloon angioplasty, in which acute luminal gain is obtained through stretching of the arterial wall,7--9 RA works by abrading and thereby debulking atherosclerotic plaques.10 The hope was that RA would reduce restenosis by decreasing the quantity of residual plaque after angioplasty, which several intravascular ultrasound studies have shown is one of the most important predictors of restenosis.11 However, it was found that the loss index, a measure of late luminal loss and thus of the efficacy of the technique in terms of restenosis, was no better than with balloon angioplasty.3 In some series in the pre-stent era, RA was associated with restenosis rates as high as 40%, despite apparently reducing barotrauma and the number of dissections.3 Several studies including DART,3 ERBAC,4 STRATAS5 and CARAT,6 as well as meta-analyses,12 did not support the use of RA as a means of reducing restenosis. As a result the technique fell out of favor and is currently employed in less than 5% of procedures in Europe. The widespread use of bare-metal stents, particularly after 1995, led to a new phenomenon, in-stent restenosis. RA was the obvious technique to treat this since it enabled