Planned versus unplanned rotational atherectomy for plaque modification in severely calcified coronary lesions

Background Evidence on the optimal timing of RA is scarce, although increased periprocedural complications for unplanned procedures have been reported. Aims To compare planned versus unplanned use of rotational atherectomy (RA) for plaque modification in patients with severely calcified coronary lesions. Methods Procedural and 1-year follow-up data of planned ( n = 562 lesions in 448 vessels of 416 patients) and unplanned ( n = 490 lesions in 435 vessels of 403 patients) RA between 2008 and 2020 were analyzed using the propensity score methods. The primary composite endpoint was target lesion failure (TLF), defined as cardiovascular death (CVD), target vessel myocardial infarction (TVMI), or target lesion revascularization (TLR). Results Angiographic success was > 99% in both groups. Fluoroscopy time and contrast volume were significantly lower in planned RA ( p < 0.001). Periprocedural complications including slow-flow, coronary dissection, and MI occurred in 4.8% after planned, and in 5.7% after unplanned RA. TLF occurred in 18.5% after planned, and in 14.7% after unplanned RA. Weighted subdistribution hazard ratios for TLFs revealed an unfavorable 1-year outcome for planned RA (sHR 1.62 [1.07–2.45], p = 0.023), which was driven by TLR (sHR 2.01 [1.18–3.46], p = 0.011), but not by CVD, or TVMI. No differences were observed in all-cause mortality. Conclusions Unplanned RA was associated with favorable outcome when compared to planned RA. Thus, RA can safely be reserved for lesions that prove untreatable by conventional means. Randomized and prospective trials are needed to evaluate a predominant use of rotational atherectomy as a bailout strategy in the future. Graphical abstract