Background: Rotational atherectomy (RA) is essential for the preparation of severely calcified coronary lesions. However, in the presence of target vessel tortuosity, RA becomes technically challenging, and its outcomes in such anatomically complex settings have not been thoroughly investigated.
Aim: To investigate the in-hospital and one-year adverse outcomes after RA of severely calcified lesions in moderately to severely tortuous target vessels.
Methods: Patients who underwent rotational atherectomy (RA) at a single center between 2010 and 2022 were divided into two groups: those with none to mild (n = 422) and those with moderate/severe (n = 288) target vessel tortuosity. In-hospital adverse outcomes and one-year rates of major adverse cardiac events (MACE) were analysed. At one-year follow-up, MACE was defined as a composite of cardiac death, spontaneous MI, or target vessel revascularization (TVR).
Results: Patients with moderate/severe tortuosity were younger (76.0 [70.2–80.8] vs. 77.1 [71.6–82.0] years, p = 0.035), had longer procedures (94 [70–125] vs. 79 [57–106] min, p < 0.001), and required more contrast (227 [173–300] vs. 200 [150–256] mL, p < 0.001). moderate/severe tortuosity was more frequently located in the RCA (45.2% vs. 20.9%, p < 0.001), with greater use of guide-extension catheters (20.5% vs. 6.7%, p < 0.001). Patients with moderate/severe target vessel tortuosity had higher in-hospital adverse outcome rates (16.0% vs. 9.7%, p = 0.013), driven by more frequent persistent slow flow (4.5% vs. 1.4%, p = 0.017), and peri-procedural myocardial infarction (6.9% vs. 3.6%, p = 0.040). After adjustment for potential confounders, moderate/severe tortuosity (adj. OR 1.93, 95% CI 1.21–3.06, p=0.005), impaired left ventricular function (adj. OR 2.02, 95% CI 1.15–3.55, p=0.015), and bifurcation lesions (adj. OR 1.83, 95% CI 1.15–2.92, p=0.011) emerged as independent predictors of in-hospital adverse outcomes, whereas the use of intravascular imaging (adj. OR 0.54, 95% CI 0.31–0.94, p=0.028) was independently protective. After one year, both groups showed comparable rates of MACE (12% vs. 14%, log-rank p = 0.531), myocardial infarction (1% vs. 2%, log-rank p = 0.218), and target vessel revascularization (8% vs. 6%, log-rank p = 0.319). However, patients with moderate/severe tortuosity showed numerically lower cardiac death rates (4% vs. 7%, p = 0.052). After a multivariate analysis, cardiac mortality was comparable between study arms (adj. HR 0.56, 95% CI 0.26–1.21, p = 0.142). Conversely, chronic renal impairment (adj. HR 2.35, 95% CI 1.19–4.65, p = 0.014) and non-ST-segment elevation MI (adj. HR 2.40, 95% CI 1.04–5.61, p = 0.040) emerged as independent predictors of one-year mortality.
Conclusion: RA of severely calcified lesions in moderately to severely tortuous target vessels is challenging and resulting in higher in-hospital adverse outcomes. Nevertheless, one-year MACE rates were comparable to those in patients with none to mild target vessel tortuosity
