Percutaneous transluminal rotational atherectomy (PTRA) was advocated for the treatment of bifurcation lesions because it effectively removes plaque while minimizing injury to adjacent normal arterial segments compared with standard BA, and it avoids “snow” plaque shifting. Several investigators reported their experience with PTRA in the treatment of bifurcation lesions; most of those studies were limited by the small number of patients studied and lack of randomization when compared with other treatment modalities (Table 30.1) (4, 5, 6, 7, 8). Warth et al. (4) reported the results from a multicenter registry that included 709 consecutive patients with 847 lesions treated with rotational atherectomy between 1988 and 1991, of which 166 (27.1%) lesions were bifurcation lesions. The procedure success rate in bifurcation lesions was >80% using PTRA alone and >90% with PTRA and adjunctive or complementary angioplasty. Overall, the major complications rate was 3% (0.8% death rate, 0.8% Q-wave MI, and 1.7% CABG). Acute occlusion occurred in 3.1% of procedures. Complication rates were higher in bifurcation lesions (32.5% versus 19.4%, p <0.01). In multivariate analysis bifurcation lesions treated with rotational atherectomy was significantly associated with emergency CABG and abrupt occlusion (p <0.05). The overall restenosis rate was 37.7%. Neither bifurcation lesion intervention nor adjunctive angioplasties were independent predictors of restenosis.

The study to Determine Rotablator and Transluminal Angioplasty Strategy (STRATAS) (5,6) enrolled 500 patients treated with rotational atherectomy. A total of 63 patients underwent bifurcation lesions intervention. Of these, 33 lesions were treated using routine rotablation strategy, and 35 lesions were treated using an aggressive rotablation strategy (5). Mean reference vessel diameter was 2.64 mm, and final percent area stenosis was 28.5%. Coronary stenting was performed in 38 (7.6%) patients. Clinical success was over 90%. Death, Q-wave MI, and CABG did not occur in any patient. Side-branch occlusion was encountered in five cases (7.9%), emerging as the only difference between bifurcation lesions when compared to nonbifurcation lesions (6). The target lesion revascularization (TLR) rate was 26%. It is not clear from the above two studies (4, 5, 6) how many of these patients were treated with ablation in both the parent vessel and the side-branch.

Rihal et al. (7) reported results in 15 patients with bifurcation lesions treated with rotational atherectomy; both limbs were treated with rotablation in seven patients and only one limb in eight patients. Adjunctive BA was performed in 73% of bifurcation lesion arms, five treated with
stents in one limb and two treated with stents in both limbs. No side-branch compromise occurred and the success rate was 100%. Long-term follow-up was not reported.

More recently, Nageh et al. (8) evaluated the role of PTRA in 32 lesions and compared them with 118 lesions treated with BA (provisional stenting was performed in both groups) in a nonrandomized fashion. The PTRA group had a higher success rate (97% versus 81%) and lower in-hospital event rate (9% versus 14.4%). Furthermore, at a mean follow-up of 15 months, PTRA was associated with reduced cardiac events (22.5% versus 27.5%) and target lesion revascularization (18.7% versus 23%) when compared to BA.

The available literature suggests that rotational atherectomy appears to be successful in treating bifurcation lesions, and it may have a role in facilitating angioplasty and stenting.

Several investigators evaluated the role of directional atherectomy in the treatment of bifurcation lesions (Table 30.2) (9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22); most of these studies were limited by the small number of patients enrolled. Although some investigators advocated the use of nitinol guidewires to protect the sidebranch (13,15), the vast majority of studies performed DCA sequentially, with atherectomy being performed first in the parent vessel followed by treatment of the sidebranch. Studies varied in the use of adjunctive BA and stenting.