Rotablation Should NOT Be Used to Ablate a Previously Placed Stent
Rotational atherectomy is designed to modify inelastic atherosclerotic tissue and calcified plaque BEFORE stent placement, not to ablate stents themselves. The 2021 ACC/AHA/SCAI guidelines explicitly state that rotational atherectomy "excavates inelastic atherosclerotic tissue through the use of a diamond-tipped burr" and is used to "prepare" a lesion for stenting, not to treat stents 1.
Why Rotablation Cannot Ablate Stents
The fundamental mechanism of rotational atherectomy makes it incompatible with stent ablation:
- Rotational atherectomy uses a diamond-tipped burr rotating at 140,000-180,000 rpm to pulverize atherosclerotic plaque and calcium 1
- The device is specifically designed to selectively ablate inelastic tissue while theoretically sparing elastic vessel wall 1
- Metal stents are neither atherosclerotic tissue nor calcium—they are permanent metallic scaffolds that cannot be "pulverized" by the rotablator burr 1
The Correct Clinical Indication for Rotablation
Rotational atherectomy has a Class 2a, Level B-R recommendation for fibrotic or heavily calcified lesions to improve procedural success BEFORE stent placement 1:
- Use rotablation when lesions cannot be crossed by a balloon or adequately dilated before planned stenting 1
- Calcium deposits thicker than 500 μm or involving >270° arc of the vessel on intravascular imaging predict the need for rotational atherectomy 1
- The goal is to facilitate stent delivery and expansion in heavily calcified vessels 1
Management of In-Stent Restenosis
For patients with previous stent placement who develop restenosis, rotablation is controversial and generally NOT recommended 1:
- The 2005 European Society of Cardiology guidelines explicitly state: "In general, we do not support the use of rotablation for in-stent restenosis" 1
- While rotablation has been suggested for in-stent restenosis because tissue ablation might be more efficacious than balloon compression, this strategy remains controversial 1
- The mechanism would be to ablate neointimal hyperplasia WITHIN the stent, not the stent itself 1
Alternative Approaches for Stented Vessels
When dealing with a patient who has a previously placed stent:
- For in-stent restenosis: Consider drug-coated balloons (Class I, Level A recommendation from ESC) 2, 3
- For underdeployed stents: Use high-pressure balloon angioplasty, not rotablation 1
- For severe calcification adjacent to (not within) a stent: Rotablation may be used to prepare the adjacent native vessel before extending stent coverage 4, 5
Critical Safety Considerations
Attempting to use rotablation on a stent would create severe complications:
- Risk of stent fracture, embolization, or vessel perforation
- The diamond burr cannot effectively ablate metal and would likely cause device failure
- Increased risk of no-reflow phenomenon and periprocedural myocardial infarction 1