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Page 10 of 22 Andò et al. Vessel Plus 2023;7:15 https://dx.doi.org/10.20517/2574-1209.2023.26

• Gradual advancement of the burr using a pecking technique, i.e., a rapid staking movement of the burr of
the Rotablator against the calcified lesion, avoiding continuous contact, which should result in the absence
of decelerations > 5,000 rpm which are indeed associated with a greater risk of entrapment (stall) of the
burr. The pecking maneuver should be repeated until the complete crossing of the calcific lesion is obtained
without significant decelerations. In fact, this technique prevents the burr from being pushed in a
continuous forward movement and, therefore, the possibility of crossing the entire lesion during the initial
passage. In any case, short advancements of the active burr (≤ 15-30 s) are recommended, with a sufficient
pause before the next burr activation, to allow burr cooling, clearance of the particles from the
microcirculation, and sufficient time to check patient ECG and hemodynamic parameters. Finally, a
“cleaning” or “polishing” run is always recommended in which the burr should freely move forward across
the lesion without any deceleration.

Rotational Atherectomy contraindications
“Classical” contraindications to RA include lesions in the last remaining patent vessel, lesions in patients
with depressed left ventricular function, lesions on venous bypass grafts, lesions with angiographic evidence
of thrombus or significant dissection. Despite these contraindications, several case reports in the literature
and the experience of expert operators can confirm the safety and efficacy of RA in exceptional
circumstances such as heavy calcified non-dilatable lesions in venous grafts, iatrogenic coronary dissections,
acute myocardial infarction and left main lesions in patients deemed unsuitable for surgical
[61]
revascularization . Therefore, RA remains an invaluable technical aid in the percutaneous
revascularization of high-risk patients, such as those with a single patent vessel, low LVEF and serious
comorbidities that fall within the modern definition of Complex Higher-risk and Indicated Patients (CHIP)
[72]
and are currently being successfully treated with appropriate hemodynamic circulatory support .

Prevention and management of complications of Rotational Atherectomy
RA procedures are associated with the same spectrum of clinical complications as traditional PCI; however,
coronary dissection and perforation, acute vessel occlusion and slow-flow/no-reflow may be more frequent
as the risk of these complications is greater in case of severely calcified lesions regardless of the use of
[73]
RA . In highly tortuous and angulated vessels, the risk of coronary perforation with RA is higher. A
[74]
specific complication of RA is burr entrapment.

Slow-flow/no-reflow can determine a deterioration of patient hemodynamics as they compromise the
contractility of the myocardial territory subtended by the treated vessel. The pathogenesis is multifactorial
and includes not only distal embolization of pulverized plaque, but also coronary spasm and platelet
activation and aggregation elicited by contact of the burr with the vessel wall. No-reflow can be treated with
intracoronary vasodilators (nitroglycerin, adenosine, verapamil, nitroprusside), but the hypotension
induced by these drugs can accentuate the slow-flow and, sometimes, the aid of mechanical circulatory
support (MCS) may be necessary. Abciximab reduces the transient hypoperfusion observed during RA and
periprocedural myocardial infarction , but a word of caution is needed when considering the use of
[75]
glycoprotein IIb/IIIa inhibitors (GPI) during RA procedures because of their bleeding potential. Burr
entrapment is a complication feared by operators but which can be effectively prevented with the
application of meticulous technique [62,63] and which occurs more frequently in cases of aggressive
advancement of the burr through eccentric lesions in tortuous, angulated and extremely calcified vessels. If
the burr passes an incompletely ablated lesion, its retrieval proximal to the lesion may be impeded by the
absence of the diamond surface on its posterior half, which makes retrograde ablation impossible. During
its advancement through the calcified lesions, the burr must continue to rotate without decelerations
> 5,000 rpm. The signs of an imminent risk of entrapment are the tactile sensation of resistance to