Optimizing rotational atherectomy in high-risk percutaneous coronary interventions: Insights from the PROTECT ΙΙ study

Objective To study rotational atherectomy (RA) outcomes in patients undergoing high-risk PCI randomized to receive hemodynamic support using either IABP or Impella 2.5 in the PROTECT II trial. Background RA of heavily calcified lesions is often necessary for complex PCI but can be associated with slow-flow, hypotension, and higher risk of periprocedural MI. Methods We compared baseline, angiographic, procedural characteristics, and outcomes of patients treated with and without RA. We examined also RA technique and outcomes. Results RA was used in 52 of 448 patients (32 with Impella vs 20 with IABP, P-=-0.08). RA patients were older (72 vs. 67 yo, P-=-0.0009), more likely to have prior CABG (48 vs. 32%, P-=-0.017), higher STS (8.1 vs. 5.7, P-=-0.012) and higher SYNTAX scores (37 vs. 29, P-<-0.0001). At 90 days, RA use was associated with higher incidence of MI but no mortality difference. RA was used more aggressively with Impella resulting in higher rate of periprocedural MI (P-<-0.01), with no difference in mortality between groups (P-=-0.78). Repeat revascularization occurred less frequently with Impella (P-<-0.001). There were no differences in 90-day major adverse events between IABP and Impella in patients undergoing RA (P-=-0.29). In patients not treated with RA, fewer MAEs were observed with Impella compared with IABP (P-=-0.03). Conclusions Patients who were treated with RA had more comorbidities, and more complex and extensive coronary artery disease. In patients with Impella, more aggressive RA use resulted in fewer revascularization events but higher incidence of periprocedural MI.