The International Journal of Cardiovascular Imaging

, Volume 34, Issue 9, pp 1365–1371 | Cite as

Intravascular ultrasound assessment of the effects of rotational atherectomy in calcified coronary artery lesions

  • Sung Sik Kim
  • Myong Hwa Yamamoto
  • Akiko Maehara
  • Novalia Sidik
  • Kohei Koyama
  • Colin Berry
  • Keith G. Oldroyd
  • Gary S. Mintz
  • Margaret McEntegart
Original Paper


We sought to clarify intravascular ultrasound (IVUS) features of rotational atherectomy (RA) of calcified lesions. IVUS was performed post-RA and post-stent in 38 lesions and analyzed every 1 mm. Pre-intervention IVUS was performed when the IVUS catheter crossed the lesion (n = 11). Calcium Index was average calcium angle multiplied by calcium length. We compared lowest (n = 13), middle (n = 13), and highest (n = 12) Calcium Index tertiles. Reverberations (multiple reflections from calcium) with a concave-shaped lumen in the post-RA IVUS were considered to represent RA-related calcium modification. Newly visible perivascular tissue through a previously solid arc of calcium in the post-stent IVUS was also evaluated. Comparing the pre and post-RA IVUS, maximum reverberation angle, and length increased significantly after RA (angle, from 45° [31, 67] to 96° [50, 148], p = 0.003; length, from 4.0 mm [2.0, 6.0] to 8.0 mm [4.0, 14.0], p = 0.005). In the post-RA IVUS, reverberations had a larger angle in the middle and highest Calcium Index tertiles (lowest, 91° [64, 133]; middle, 135° [107, 201]; highest, 150° [93, 208], p = 0.03). Post-stent newly visible perivascular tissue was more frequent in the middle and highest Calcium Index tertiles (lowest, 30.8%; middle, 69.2%; highest, 75.0%, p = 0.049). Minimum stent area was similar after calcium modification by RA irrespective of the severity of the Calcium Index (lowest, 6.7 mm2 [5.7, 8.9]; middle, 5.6 mm2 [4.9, 6.8]; highest, 6.7 mm2 [5.9, 8.2], p = 0.2). Greater calcium modification by RA occurs in severely calcified lesions with smaller lumen diameters to mitigate against stent underexpansion.


Intravascular ultrasound Rotational atherectomy Calcified lesions 


Compliance with ethical standards

Conflict of interest

Akiko Maehara has received consulting fees from ACIST, Boston Scientific, and St Jude Medical, and research grants from Boston Scientific; Gary S. Mintz has received consulting fees from ACIST, Boston Scientific, St Jude, and Volcano. The rest of the authors have no conflicts to report.

Ethical approval

The study protocol was approved by the institutional ethics committee of Golden Jubilee National Hospital, and written informed consent was obtained from all patients in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.


  1. 1.
    Kawaguchi R, Tsurugaya H, Hoshizaki H et al (2008) Impact of lesion calcification on clinical and angiographic outcome after sirolimus-eluting stent implantation in real-world patients. Cardiovasc Revasc Med 9:2–8CrossRefPubMedGoogle Scholar
  2. 2.
    Nishida K, Kimura T, Kawai K et al (2013) Comparison of outcomes using the sirolimus-eluting stent in calcified versus non-calcified native coronary lesions in patients on- versus not on-chronic hemodialysis (from the j-Cypher registry). Am J Cardiol 112:647–655CrossRefPubMedGoogle Scholar
  3. 3.
    Bourantas CV, Zhang YJ, Garg S et al (2014) Prognostic implications of coronary calcification in patients with obstructive coronary artery disease treated by percutaneous coronary intervention: a patient-level pooled analysis of 7 contemporary stent trials. Heart 100:1158–1164CrossRefPubMedGoogle Scholar
  4. 4.
    Généreux P, Redfors B, Witzenbichler B et al (2017) Two-year outcomes after percutaneous coronary intervention of calcified lesions with drug-eluting stents. Int J Cardiol 231:61–67CrossRefPubMedGoogle Scholar
  5. 5.
    Abdel-Wahab M, Richardt G, Joachim Büttner H et al (2013) High-speed rotational atherectomy before paclitaxel-eluting stent implantation in complex calcified coronary lesions: the randomized ROTAXUS (Rotational Atherectomy Prior to Taxus Stent Treatment for Complex Native Coronary Artery Disease) trial. JACC Cardiovasc Interv 6:10–19CrossRefPubMedGoogle Scholar
  6. 6.
    Hoffmann R, Mintz GS, Popma JJ et al (1998) Treatment of calcified coronary lesions with Palmaz-Schatz stents. An intravascular ultrasound study. Eur Heart J 19:1224–1231CrossRefPubMedGoogle Scholar
  7. 7.
    Kobayashi Y, Okura H, Kume T et al (2014) Impact of target lesion coronary calcification on stent expansion. Circ J 78:2209–2214CrossRefPubMedGoogle Scholar
  8. 8.
    Madhavan MV, Tarigopula M, Mintz GS et al (2014) Coronary artery calcification: pathogenesis and prognostic implications. J Am Coll Cardiol 63:1703–1714CrossRefPubMedGoogle Scholar
  9. 9.
    Barbato E, Carrié D, Dardas P et al (2015) European expert consensus on rotational atherectomy. EuroIntervention 11:30–36CrossRefPubMedGoogle Scholar
  10. 10.
    Kawamoto H, Latib A, Ruparelia N et al (2016) In-hospital and midterm clinical outcomes of rotational atherectomy followed by stent implantation: the ROTATE multicentre registry. EuroIntervention 12:1448–1456CrossRefPubMedGoogle Scholar
  11. 11.
    Eftychiou C, Barmby DS, Wilson SJ et al (2016) Cardiovascular outcomes following rotational atherectomy: A UK Multicentre Experience. Catheter Cardiovasc Interv 88:546–553CrossRefPubMedGoogle Scholar
  12. 12.
    Mintz GS, Potkin BN, Keren G et al (1992) Intravascular ultrasound evaluation of the effect of rotational atherectomy in obstructive atherosclerotic coronary artery disease. Circulation 86:1383–1393CrossRefPubMedGoogle Scholar
  13. 13.
    Kovach JA, Mintz GS, Pichard AD et al (1993) Sequential intravascular ultrasound characterization of the mechanisms of rotational atherectomy and adjunct balloon angioplasty. J Am Coll Cardiol 22:1024–1032CrossRefPubMedGoogle Scholar
  14. 14.
    Popma J, Almonacid A, Burke D (2011) Qualitative and quantitative coronary angiography. In: Topol EJ, Teirstein PS (eds) Textbook of interventional cardiology, 6th edn. Saunders, Philadelphia, pp, 757–775Google Scholar
  15. 15.
    Mintz GS, Nissen SE, Anderson WD (2001) American college of cardiology clinical expert consensus document on standards for acquisition, measurement and reporting of intravascular ultrasound studies (IVUS). A report of the American College of Cardiology Task Force on clinical expert consensus documents. J Am Coll Cardiol 37:1478–1492CrossRefPubMedGoogle Scholar
  16. 16.
    Mosseri M, Satler LF, Pichard AD et al (2005) Impact of vessel calcification on outcomes after coronary stenting. Cardiovasc Revasc Med 6:147–153CrossRefPubMedGoogle Scholar
  17. 17.
    Liu X, Doi H, Maehara A et al (2009) A volumetric intravascular ultrasound comparison of early drug-eluting stent thrombosis versus restenosis. JACC Cardiovasc Interv 2:428–434CrossRefPubMedGoogle Scholar
  18. 18.
    Généreux P, Madhavan MV, Mintz GS et al (2014) Ischemic outcomes after coronary intervention of calcified vessels in acute coronary syndromes. Pooled analysis from the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) and ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) TRIALS. J Am Coll Cardiol 63:1845–1854CrossRefPubMedGoogle Scholar
  19. 19.
    Tomey MI, Kini AS, Sharma SK (2014) Current status of rotational atherectomy. JACC Cardiovasc Interv 7:345–353CrossRefPubMedGoogle Scholar
  20. 20.
    Mintz GS (2015) Intravascular imaging of coronary calcification and its clinical implications. JACC Cardiovasc Imaging 8:461–471CrossRefPubMedGoogle Scholar
  21. 21.
    Mintz GS (2004) Intracoronary ultrasound. CRC Press, LondonGoogle Scholar
  22. 22.
    Feldman MK, Katyal S, Blackwood MS (2009) US artifacts. Radiographics 29:1179–1189CrossRefPubMedGoogle Scholar
  23. 23.
    Yamamoto MH, Maehara A, Karimi Galougahi K et al (2017) Mechanisms of orbital versus rotational atherectomy plaque modification in severely calcified lesions assessed by optical coherence tomography. JACC Cardiovasc Interv 10:2584–2586CrossRefPubMedGoogle Scholar
  24. 24.
    Kubo T, Shimamura K, Ino Y et al (2015) Superficial calcium fracture after PCI as assessed by OCT. JACC Cardiovasc Imaging 8:1228–1229CrossRefPubMedGoogle Scholar
  25. 25.
    Maejima N, Hibi K, Saka K et al (2016) Relationship between thickness of calcium on optical coherence tomography and crack formation after balloon dilatation in calcified plaque requiring rotational atherectomy. Circ J 80:1413–1419CrossRefPubMedGoogle Scholar
  26. 26.
    Vavuranakis M, Toutouzas K, Stefanadis C et al (2001) Stent deployment in calcified lesions: can we overcome calcific restraint with high-pressure balloon inflations? Catheter Cardiovasc Interv 52:164–172CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  • Sung Sik Kim
    • 1
    • 2
  • Myong Hwa Yamamoto
    • 1
    • 2
  • Akiko Maehara
    • 1
    • 2
  • Novalia Sidik
    • 3
  • Kohei Koyama
    • 1
    • 2
  • Colin Berry
    • 3
  • Keith G. Oldroyd
    • 3
  • Gary S. Mintz
    • 1
  • Margaret McEntegart
    • 3
  1. 1.Clinical Trials CenterCardiovascular Research FoundationNew YorkUSA
  2. 2.NewYork-Presbyterian Hospital/Columbia University Medical CenterNew YorkUSA
  3. 3.Golden Jubilee National HospitalGlasgowUK

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