Rotational atherectomy Flashcards
Why were atherectomy devices originally developed?
A. To improve stent delivery in calcified vessels
B. To decrease restenosis rates after PTCA
C. To replace balloon angioplasty as the primary intervention
D. To treat aneurysms in coronary arteries
B. To decrease restenosis rates after PTCA
Which of the following atherectomy devices was introduced first?
A. Rotational atherectomy (RA)
B. Helium laser angioplasty (ELCA)
C. Cutting balloon angioplasty (CBA)
D. Orbital atherectomy (OA)
A. Rotational atherectomy (RA)
In what year was orbital atherectomy (OA) introduced?
A. 1988
B. 1990
C. 1991
D. 2008
D. 2008
What is the primary use of atherectomy devices in the current era?
A. To reduce long-term restenosis rates
B. To debulk heavily calcified vessels and facilitate stent delivery
C. To eliminate the need for balloon angioplasty
D. To treat non-calcified coronary lesions
B. To debulk heavily calcified vessels and facilitate stent delivery
Which atherectomy device was introduced in 1990?
A. Rotational atherectomy (RA)
B. Helium laser angioplasty (ELCA)
C. Cutting balloon angioplasty (CBA)
D. Orbital atherectomy (OA)
B. Helium laser angioplasty (ELCA)
What is the principal mechanism of action for rotational atherectomy (RA)?
A. Thermal ablation
B. Differential cutting
C. Chemical dissolution of plaque
D. Balloon inflation and compression
B. Differential cutting
What type of tip does the rotational atherectomy (RA) device use to drill through plaque?
A. Laser tip
B. Balloon tip
C. Diamond-tipped burr
D. Metal blade
C. Diamond-tipped burr
What is the primary target of the diamond-tipped burr in rotational atherectomy?
A. Elastic arterial structure
B. Atherosclerotic plaque and calcium
C. Healthy endothelial cells
D. Coronary microcirculation
B. Atherosclerotic plaque and calcium
Why does rotational atherectomy spare the underlying elastic arterial structure?
A. Because of its low rotational speed
B. Due to the property of differential cutting
C. It selectively targets soft tissues
D. It emits low-frequency vibrations
B. Due to the property of differential cutting
What happens to the particulate matter generated by rotational atherectomy?
A. It is absorbed by the arterial wall
B. It passes through the microcirculation and is picked up by the reticuloendothelial system
C. It clogs the coronary microcirculation
D. It is removed through suction during the procedure
B. It passes through the microcirculation and is picked up by the reticuloendothelial system
What is the typical size of the particulate matter produced by rotational atherectomy?
A. Less than 10 μm in diameter
B. 50-100 μm in diameter
C. 100-200 μm in diameter
D. Greater than 200 μm in diameter
A. Less than 10 μm in diameter
What is the most common indication for using rotational atherectomy (RA)?
A. Routine use in all coronary lesions
B. Preparing vessels with severe fibrocalcific disease
C. Treating non-calcified coronary stenosis
D. Managing coronary aneurysms
B. Preparing vessels with severe fibrocalcific disease
Why is RA used before stent placement in calcific lesions?
A. To completely dissolve the plaque
B. To facilitate the passage and proper positioning of stents
C. To eliminate the need for drug-eluting stents
D. To reduce the risk of coronary spasms
B. To facilitate the passage and proper positioning of stents
Which of the following complications may occur if a stent is passed through a rigid, calcific lesion without using RA?
A. Stent dislodgement
B. Inappropriate stent positioning
C. Erosion of the polymer–drug coating
D. All of the above
D. All of the above
Which of the following is NOT an indication for using rotational atherectomy?
A. Severe fibrocalcific coronary disease
B. When balloons or stents cannot be passed through a lesion
C. Routine treatment of non-calcified plaques
D. To improve immediate angiographic results in calcified lesions
C. Routine treatment of non-calcified plaques
What is a potential risk if RA is not used before stent deployment in severely calcified vessels?
A. Inadequate drug delivery to the vessel wall
B. Enhanced polymer integrity of drug-eluting stents
C. Increased plaque elasticity
D. Reduced risk of restenosis
A. Inadequate drug delivery to the vessel wall
Why might high-pressure balloon expansion be required in highly calcified lesions?
A. To dissolve the calcified plaque
B. Due to increased vessel stiffness
C. To prevent vessel dissection
D. To enhance drug delivery from stents
B. Due to increased vessel stiffness
What are the potential risks associated with high-pressure balloon expansion in calcified lesions?
A. Balloon rupture
B. Vessel dissection
C. Vessel perforation
D. All of the above
D. All of the above
What complication may occur if a stent is delivered in an incompletely dilated calcified lesion?
A. Stent migration
B. Stent thrombosis
C. Enhanced drug elution
D. Increased vessel elasticity
B. Stent thrombosis
Why does incomplete expansion of a stent in a calcified lesion increase the risk of stent thrombosis?
A. It enhances endothelial healing
B. It leads to improper stent apposition
C. It improves blood flow dynamics
D. It increases polymer adhesion
B. It leads to improper stent apposition
Which of the following is a key reason for using rotational atherectomy in highly calcified nonyielding lesions?
A. To reduce the risk of balloon rupture and vessel perforation
B. To avoid the use of drug-eluting stents
C. To enhance vessel elasticity permanently
D. To treat non-calcified coronary stenosis
A. To reduce the risk of balloon rupture and vessel perforation
Why is rotational atherectomy (RA) used in bifurcation lesions?
A. To promote endothelial growth
B. To reduce plaque shift or the “snow-plowing” effect
C. To prevent vessel rupture
D. To eliminate the need for stent placement
B. To reduce plaque shift or the “snow-plowing” effect
What is a potential risk when using RA in bifurcation lesions?
A. Enhanced plaque stability
B. Increased risk of dissection or perforation
C. Reduced procedural time
D. Decreased need for antiplatelet therapy
B. Increased risk of dissection or perforation
Which angulation between the main vessel and side branch is a relative contraindication for RA?
A. Less than 30 degrees
B. More than 60 degrees
C. Exactly 45 degrees
D. Greater than 120 degrees
B. More than 60 degrees
At what vessel angulation is RA strongly contraindicated?
A. 45 degrees
B. 60 degrees
C. Greater than 90 degrees
D. Less than 30 degrees
C. Greater than 90 degrees
Which of the following is a relative contraindication for RA?
A. Lesion length more than 25 mm
B. Bends less than 45 degrees
C. Small vessel diameter (<2 mm)
D. High ejection fraction (>60%)
A. Lesion length more than 25 mm
What size burr is recommended if RA is chosen for lesions longer than 25 mm?
A. Larger than 2.5 mm
B. Exactly 2 mm
C. Smaller than 1.5 mm
D. No burr should be used
C. Smaller than 1.5 mm
Why was reduced ejection fraction (<30%) previously considered a contraindication for RA?
A. Due to the risk of coronary spasm
B. Due to concerns about hemodynamic instability
C. Because of high rates of stent thrombosis
D. It leads to excessive plaque fragmentation
B. Due to concerns about hemodynamic instability
Which device has allowed the reconsideration of RA in patients with reduced ejection fraction (<30%)?
A. Balloon pump
B. Impella catheter
C. Ventricular pacemaker
D. Intravascular ultrasound (IVUS)
B. Impella catheter
What are the indications for rotational artherectomy?
Single-vessel atherosclerotic coronary artery disease with a calcified plaque that can be passed with a guidewire
Low-risk, multivessel coronary artery disease
De novo lesion < 25mm in length
What are the high-risks for rotational atherectomy?
Severe, diffuse multivessel coronary artery disease
Unprotected left main PCI
Patients with compromised LV function (LVEF < 30%)
De novo lesion > 25mm in length
Severely angulated (>45 degrees) lesions
Last remaining conduit with compromised LV function
Angiographic evidence of thrombus
What are the contraindications for rotational atherectomy?
Occlusions where a guidewire cannot be passed
Saphenous vein graft PCI
Angiographic evidence of significant dissection Type C or greater at the treatment site
What material is the burr of the Rotablator system made of?
A. Stainless steel
B. Nickel-coated brass
C. Titanium alloy
D. Carbon fiber
B. Nickel-coated brass
How many microscopic diamond crystals coat the Rotablator burr?
A. 100 to 500
B. 1000 to 1500
C. 2000 to 3000
D. More than 5000
C. 2000 to 3000
What is the size of the diamond crystals on the Rotablator burr?
A. 5 μm
B. 10 μm
C. 20 μm
D. 50 μm
C. 20 μm
What is the range of burr sizes available for the Rotablator system?
A. 0.50 to 1.25 mm
B. 1.25 to 2.50 mm
C. 2.50 to 4.00 mm
D. 3.00 to 5.00 mm
B. 1.25 to 2.50 mm
Which guide wire is used with the Rotablator system?
A. Whisper wire
B. RotaWire
C. Pilot wire
D. Runthrough wire
B. RotaWire
What is the rotation speed range of the Rotablator burr?
A. 10,000 to 50,000 rpm
B. 60,000 to 100,000 rpm
C. 140,000 to 220,000 rpm
D. 250,000 to 300,000 rpm
C. 140,000 to 220,000 rpm
What is the purpose of the emulsifier solution (Rotaglide) used with the Rotablator system?
A. To enhance plaque dissolution
B. To reduce friction and improve heat dissipation
C. To increase rotational speed
D. To enhance imaging quality
B. To reduce friction and improve heat dissipation
What are the main components of the Rotaglide emulsifier solution?
A. Egg yolk, EDTA, and olive oil
B. Saline, glucose, and heparin
C. Alcohol, iodine, and saline
D. Glycerin, water, and electrolytes
A. Egg yolk, EDTA, and olive oil
Which feature is unique to the newer RotaPro RA system compared to the traditional Rotablator system?
A. Use of a foot pedal for activation
B. Manual rotation control
C. Digital console with buttons on the advancer for activation
D. Use of external power source
C. Digital console with buttons on the advancer for activation
What is the purpose of the Dynaglide mode in the RotaPro system?
A. To increase rotational speed for plaque removal
B. To facilitate easy burr retrieval
C. To enhance imaging quality
D. To reduce saline consumption
B. To facilitate easy burr retrieval
What is the recommended burr-to-artery ratio for patent but stenotic vessels in RA?
A. Less than 0.4
B. Less than 0.6
C. Exactly 0.8
D. Greater than 1.0
B. Less than 0.6
What is the risk associated with using a burr-to-artery ratio greater than 0.6?
A. Increased risk of dissection and perforation
B. Reduced rotational speed
C. Incomplete plaque removal
D. Increased endothelial regeneration
A. Increased risk of dissection and perforation
Which burr size is recommended to start with for vessels with subtotal occlusions?
A. 0.75 mm
B. 1.25 or 1.5 mm
C. 2.0 mm
D. 2.5 mm
B. 1.25 or 1.5 mm
Why is a smaller burr size initially chosen for subtotal occlusions?
A. To create a pilot channel before upsizing
B. To maximize plaque removal in one pass
C. To reduce procedural time
D. To avoid using contrast agents
A. To create a pilot channel before upsizing
In which of the following scenarios is a smaller burr-to-artery ratio recommended?
A. Short lesions less than 10 mm
B. Lesions longer than 25 mm
C. Completely non-calcified vessels
D. Straight, non-tortuous vessels
B. Lesions longer than 25 mm
Why should a smaller burr-to-artery ratio be used for vessels with mild tortuosity?
A. To minimize the risk of vessel dissection or perforation
B. To maximize rotational speed
C. To enhance plaque fragmentation
D. To increase procedural efficiency
A. To minimize the risk of vessel dissection or perforation
What is the primary reason for upsizing the burr after creating a pilot channel in subtotal occlusions?
A. To achieve a burr-to-artery ratio of less than 0.6
B. To increase the speed of plaque removal
C. To enhance drug delivery from stents
D. To reduce saline consumption
A. To achieve a burr-to-artery ratio of less than 0.6
Which medication is commonly given preemptively to prevent coronary spasm during RA?
A. Aspirin
B. Verapamil
C. Clopidogrel
D. Atropine
B. Verapamil
Why is heparin traditionally preferred over bivalirudin for anticoagulation in RA?
A. It enhances rotational speed
B. It is reversible in case of vessel perforation
C. It reduces plaque fragmentation
D. It eliminates the need for glycoprotein IIb/IIIa inhibitors
B. It is reversible in case of vessel perforation
What is the reason for using glycoprotein (GP) IIb/IIIa receptor antagonists during RA?
A. To enhance rotational speed
B. To counteract rotational speed-dependent platelet activation
C. To reduce saline consumption
D. To minimize contrast agent use
B. To counteract rotational speed-dependent platelet activation
Which of the following is TRUE regarding the use of temporary pacemakers during RA?
A. They are routinely required for all lesions in the RCA
B. They are no longer routinely needed due to smaller burrs and lower speeds
C. They must be used before any left circumflex intervention
D. They are mandatory for all patients receiving verapamil
B. They are no longer routinely needed due to smaller burrs and lower speeds
Which medications or maneuvers are commonly used to manage bradyarrhythmias during RA?
A. Aspirin and clopidogrel
B. Atropine, aminophylline, or vagolytic maneuvers
C. Verapamil and diltiazem
D. Epinephrine and norepinephrine
B. Atropine, aminophylline, or vagolytic maneuvers
Why might a test run be performed before RA of the RCA or dominant left circumflex?
A. To evaluate rotational speed
B. To ensure bradycardia is not being induced
C. To check the efficiency of saline infusion
D. To calibrate the burr size
B. To ensure bradycardia is not being induced
What has contributed to the lower incidence of transient heart block during RA?
A. Use of high-speed burrs
B. Smaller burrs at lower speeds
C. Routine temporary pacemaker placement
D. Increased use of verapamil
B. Smaller burrs at lower speeds
Why is it important to ensure the guide catheter is coaxial to the vessel during RA?
A. To increase rotational speed
B. To prevent dissection or wire retraction
C. To reduce saline consumption
D. To enhance drug delivery from stents
B. To prevent dissection or wire retraction
Which wire is recommended for proximal and easily crossable lesions to prevent guidewire bias?
A. Whisper wire
B. RotaFloppy wire
C. Pilot wire
D. Extrasupport RotaWire
B. RotaFloppy wire
What is guidewire bias in the context of RA?
A. When the guidewire rotates with the burr
B. When the burr differentially debrides more on the lesser curvature of the vessel
C. When the wire slips out of the lesion during rotation
D. When the guidewire enhances drug elution from stents
B. When the burr differentially debrides more on the lesser curvature of the vessel
Which wire should be used for difficult-to-cross, heavily calcified, or distal lesions?
A. RotaFloppy wire
B. Extrasupport RotaWire
C. Pilot wire
D. Hydrophilic wire
B. Extrasupport RotaWire
What can be used to exchange a 0.014-inch guidewire for the RotaWire if the lesion cannot be crossed initially?
A. High-pressure balloon
B. Low-profile over-the-wire balloon or microcatheter
C. Cutting balloon angioplasty device
D. Drug-eluting stent
B. Low-profile over-the-wire balloon or microcatheter
Why is the RotaFloppy wire preferred in more proximal lesions?
A. It provides more rotational speed
B. It prevents guidewire bias by maintaining the vessel’s natural curvature
C. It increases plaque fragmentation
D. It enhances saline infusion
B. It prevents guidewire bias by maintaining the vessel’s natural curvature
What is the main advantage of using the extrasupport RotaWire in heavily calcified lesions?
A. It reduces the risk of vessel perforation
B. It provides better support for advancing the burr
C. It increases rotational speed of the burr
D. It enhances drug delivery from stents
B. It provides better support for advancing the burr
What is the recommended speed range for testing the RA burr outside the body?
A. 100,000–120,000 rpm
B. 140,000–160,000 rpm
C. 180,000–200,000 rpm
D. 220,000–240,000 rpm
B. 140,000–160,000 rpm
What solution can be used to flush and lubricate the RA system to decrease spasm?
A. Heparinized saline
B. Rotaflush solution
C. Pure saline only
D. Dextrose solution
B. Rotaflush solution
What are the components of the Rotaflush solution?
A. 10 mg of verapamil and 5 mg of nitroglycerin in 500 mL of saline
B. 4 mg of nitroglycerin and 5 mg of verapamil in 500 mL of saline
C. 10 mg of nitroglycerin and 5 mg of heparin in 500 mL of saline
D. 4 mg of verapamil and 5 mg of nitroglycerin in 500 mL of saline
B. 4 mg of nitroglycerin and 5 mg of verapamil in 500 mL of saline
Which solution is added to reduce friction during RA?
A. Rotaflush solution
B. Rotaglide solution
C. Pure saline
D. Dextrose solution
B. Rotaglide solution
Before inserting the burr into the Y-adapter, what must be checked?
A. Burr speed at 220,000 rpm
B. Free movement of the burr with the advancer
C. Saline pressure inside the guide catheter
D. The amount of nitroglycerin used
B. Free movement of the burr with the advancer
What is the purpose of testing the braking system before the procedure?
A. To ensure the braking system holds the wire in place during rotation
B. To increase rotational speed of the burr
C. To check the saline infusion rate
D. To test the contrast injection system
A. To ensure the braking system holds the wire in place during rotation
How far should the advance knob be locked from the distal end of its slider slot?
A. 0.5 cm
B. 1 cm
C. 2 cm
D. 3 cm
C. 2 cm
How far proximal to the lesion should the burr be advanced before activation?
A. Directly on the lesion
B. 1 to 2 cm proximal to the lesion
C. 3 to 4 cm proximal to the lesion
D. At the distal end of the vessel
B. 1 to 2 cm proximal to the lesion
Why should the operator hold the back end of the wire and apply gentle traction on the guidewire and catheter during the initial pass?
A. To increase rotational speed of the burr
B. To limit acquired tension and prevent the burr from leaping forward
C. To enhance drug delivery from stents
D. To check saline flow through the guide catheter
B. To limit acquired tension and prevent the burr from leaping forward
What is the purpose of transiently activating the system proximal to the lesion before contacting the plaque?
A. To increase plaque fragmentation
B. To alleviate acquired tension
C. To enhance rotational speed of the burr
D. To test the braking system
B. To alleviate acquired tension
What is the recommended technique for contacting the plaque with the burr?
A. Continuous forward pressure
B. Rapid drilling motion
C. Pecking fashion: 1 to 3 seconds of contact followed by 3 to 5 seconds of retraction
D. High-pressure burst technique
C. Pecking fashion: 1 to 3 seconds of contact followed by 3 to 5 seconds of retraction
Why is it important to avoid decelerations greater than 5000 rpm?
A. It may cause the guidewire to fracture
B. It can lead to plaque heating, torsional dissection, and formation of larger particles
C. It reduces saline flow through the guide catheter
D. It increases the risk of wire bias
B. It can lead to plaque heating, torsional dissection, and formation of larger particles
How long should each atherectomy run last?
A. No more than 10 seconds
B. No more than 20 seconds
C. No more than 30 seconds
D. No more than 60 seconds
C. No more than 30 seconds
What is the recommended interval between each atherectomy run?
A. 10 to 20 seconds
B. 20 to 30 seconds
C. 30 to 60 seconds
D. 1 to 2 minutes
C. 30 to 60 seconds
What is a serious complication of improper technique that may require emergent surgery?
A. Guidewire fracture
B. Device entrapment beyond the target lesion
C. Rapid plaque fragmentation
D. Decrease in rotational speed
B. Device entrapment beyond the target lesion
What is the most important factor for successfully using RA?
A. High rotational speeds
B. Avoiding complications such as dissection, perforation, and no reflow
C. Using the largest possible burr size
D. Shortening the procedure time
B. Avoiding complications such as dissection, perforation, and no reflow
Which of the following is a key complication to prevent during RA?
A. Wire kinking
B. Plaque hardening
C. No reflow or slow reflow (reduction in blood flow by 1 TIMI grade)
D. Increased saline consumption
C. No reflow or slow reflow (reduction in blood flow by 1 TIMI grade)
Which factor significantly reduces the occurrence of complications in RA?
A. Use of high-pressure balloons
B. Operator experience and number of cases performed every year
C. Increasing rotational speed to maximum limits
D. Using multiple burr sizes in rapid succession
B. Operator experience and number of cases performed every year
How can an operator minimize the risk of dissection and perforation during RA?
A. By using the largest burr-to-artery ratio possible
B. By utilizing the slow pecking technique with 1 to 3 seconds of contact
C. By advancing the burr continuously without pauses
D. By increasing the speed beyond 220,000 rpm
B. By utilizing the slow pecking technique with 1 to 3 seconds of contact
Which technique helps in preventing no reflow or slow reflow?
A. Continuous forward pressure on the burr
B. Using short atherectomy runs with 30- to 60-second intervals
C. High-speed rotation without interruption
D. Applying pressure to the guide catheter during rotation
B. Using short atherectomy runs with 30- to 60-second intervals
Why is operator experience important in RA?
A. It increases the speed of the procedure
B. It allows for better selection of burr size and technique, reducing complications
C. It ensures higher contrast usage
D. It leads to greater plaque fragmentation
B. It allows for better selection of burr size and technique, reducing complications
Which adverse effect is associated with sudden deceleration of the burr?
A. Increased rotational speed
B. Plaque heating and torsional dissection
C. Enhanced stent delivery
D. Faster blood flow in distal vessels
B. Plaque heating and torsional dissection
What is the minimum required flow rate and pressure for the nitrogen compressed-gas cylinder used in RA?
A. 120 L/min at 80 to 90 psi
B. 140 L/min at 90 to 100 psi
C. 160 L/min at 110 to 120 psi
D. 180 L/min at 100 to 110 psi
B. 140 L/min at 90 to 100 psi
How should the regulator on the nitrogen compressed-gas cylinder be adjusted?
A. To maintain pressure below 80 psi
B. To maintain pressure exactly at 110 psi
C. To ensure pressure does not exceed 100 psi
D. To fluctuate between 90 and 120 psi
C. To ensure pressure does not exceed 100 psi
Which type of lesions have a higher incidence of dissection and/or perforation during RA?
A. Long, smooth lesions
B. Non-calcified soft plaques
C. Angulated lesions and branch ostial lesions
D. Distal lesions with mild stenosis
C. Angulated lesions and branch ostial lesions
What is the recommended approach for RA in angulated or branch ostial lesions?
A. Start with a smaller burr and gradually increase size
B. Use high-speed rotation immediately
C. Avoid RA entirely in these lesions
D. Use the largest burr-to-artery ratio possible
A. Start with a smaller burr and gradually increase size
When is it appropriate to perform RA on chronic total occlusions?
A. Only when the lesion is short and soft
B. When the guidewire is confirmed to be in the true lumen distally
C. When using the largest burr-to-artery ratio
D. In all chronic total occlusions regardless of wire position
B. When the guidewire is confirmed to be in the true lumen distally
What should be available in all cardiac catheterization laboratories performing RA to manage perforations?
A. High-pressure balloons
B. Temporary pacemakers
C. Covered stents
D. Intravenous heparin infusion
C. Covered stents
Why is it recommended to stepwise increase burr size during RA?
A. To accelerate the procedure
B. To minimize the risk of dissection and perforation
C. To enhance burr rotational speed
D. To reduce the need for saline flushes
B. To minimize the risk of dissection and perforation
